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COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


K)aA"VTX^M  - 


(yet.  •*** 


A  MANUAL 


OPERATIVE  SURGERY. 


BY 


LEWIS   A.  STIMSON,  B.A.,  M.D., 

SURGEON  TO  THE   NEW   YORK  AND  HUDSON  STREET   HOSPITALS  J   CONSULTING  SUR- 
GEON TO  BELLEVUE,  ST.  JOHN'S,  AND  CHRIST'S   HOSPITALS  ;    PROFESSOR    OF 
SURGERY    IN   CORNELL   UNIVERSITY;    CORRESPONDING   MEMBER 
OF  THE  SOCIETE  DE  CHIRURGIE,  PARIS. 


JOHN    ROGERS,  Jr.,  B.A.,  M.D., 

SURGEON   OF  GOUVERNEUR   HOSPITAL,   NEW   YORK;   INSTRUCTOR  OF  SURGERY 
IN   CORNELL   UNIVERSITY. 


FOURTH    AND    REVISED    EDITION. 


WITH  TWO  HUNDRED  AND  NINETY-THREE  ILLUSTRATIONS. 


PHILADELPHIA  : 

LEA   BROTHERS   &   CO. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1900,  by 

LEA   BKOTHERS  &  CO., 
In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved. 


PREFACE  TO  FOURTH  EDITION. 


In  this  fourth  edition  the  principles  which  guided  the 
preparation  of  the  third  have  again  been  followed,  and 
the  part  given  to  conclusions  drawn  from  personal  experi- 
ence has  again  been  somewhat  increased. 

The  size  of  the  book  has  been  reduced  by  omission  of 
portions  of  the  text  and  of  about  forty  cuts  which  seemed 
to  ha%re  outlived  their  usefulness. 

LEWIS   A.  STIMSON. 


CONTENTS. 


PART   I. 


TIIK  ACCESSORIES   OF   AN   OPERATION. 


Anesthesia. 

Local, 

General, 

Administration    of    the    anaes- 
thetic, 

Rectal, 
Arrest  of  hemorrhage, 

Ligature, 

Torsion, 

Pressure, 

Cold  or  heat. 

Position, 
Artificial  ischemia. 
Sutures, 

Interrupted, 

Continuous, 


PAGE 

PALE 

17 

Sutures,  twisted, 

25 

17 

Preparation  of  materials  used  in  an 

18 

operation. 

26 

Catgut, 

26 

19 

chromicized, 

26 

20 

Silk, 

26 

20 

Silkworm-gut, 

26 

20 

Sponges, 

26 

20 

Absorbent  gauze, 

27 

20 

Bichloride  gauze. 

27 

22 

Iodoform  gauze, 

27 

22 

Drainage-tubes, 

28 

23 

Absorbent  cotton, 

28 

25 

Rubber  tissue, 

28 

25 

Sterilization, 

28 

25 

The  wound  and  its  treatment, 

29 

PART   II. 


LIGATURE   OF   ARTERIES. 


General  directions,  33 
Anatomy    of    the    supra-clavicular 

region,  35 

Ligature  of  the  innominate  artery,  37 

Anatomy,  37 

Operation,  ::7 

Ligature  of  the  subclavian  artery,  ::;i 

1st  portion,  left  subclavian,  39 

1st  portion,  right  subclavian,  40 

2d  portion,  40 

3d  portion,  40 

Ligature  of  the  superior  thyroid,  41 

Ligature  of  the  inferior  thyroid,  42 

Ligature  of  the  vertebral  artery,  43 

Ligature  of  the  axillary  artery,  43 

Under  the  clavicle,  44 

In  the  axilla,  44 

Ligature  of  the  brachial  artery,  45 

Anatomy,  4.~> 

Operation,  47 

Ligature  of  the  radial  artery.  47 

Anatomy,  47 

Operation,  upper  third,  48 

Operation,  lower  third.  4s 

Ligature  of  the  ulnar  artery.  V.i 

Anatomy,  4'J 

Operation  at  the  junction  of  the 

upper  and  middle  third-.  49 

Operation  in  the  lower  third,  49 


Ligature  of  the  common  carotid, 

At  the  place  of  election, 
Ligature  of  the  external  carotid, 
Anatomy. 
Operation. 
Ligature  of  the  internal  carotid. 
Ligature  of  the  lingual  artery. 
Anatomy, 
Operation, 
Ligature  of  the  facial  artery. 
Ligature  of  the  occipital  artery. 
Ligature  of  the  temporal  artery, 
Ligature  of  the  abdominal  aoi  ta. 
Ligature  of  the  common  iliac, 

Anatomy  of  the  common,  inter- 
nal and  external  iliac  arteries. 
Extra-peritoneal, 
Intra-peritoneal, 
Ligature  of  the  internal  iliac, 
Ligature  of  the  external  iliac. 
Ligature  of  the  gluteal,  sciatic  and 

internal  pudic  arteries, 
Ligature  of  the  femoral  artery, 
Anatomy, 
Operation, 

At  the  apex  of  Scarpa's  tri- 
angle, 
In  the  middle  of  the  thigh, 
In  Hunter's  canal, 


VI 


CONTENTS. 


Ligature  of  the  popliteal  artery, 
Ligature  of  the  anterior  tibial, 

Anatomy, 

Operation, 
Ligature  of  the  dorsalis  pedis, 


PA  OF. 

65 
65 
65 
66 

67 


PAGE 

Ligature  of  the  posterior  tibial,  67 

Outline's  method,  67 

Lateral  method,  67 

In  the  lower  third   and  behind 

the  ankle,  69 


PART  III. 


AMPUTATIONS. 


Circular  method, 
1st  step, 
2d  step, 

(6)  Cutaneous  sleeve, 
3d  step, 
Oval  method, 
Flap  method, 

.Skin  flaps  and  circular  division, 
Long  anterior  flap, 
Teale's  method, 
Amputation  of  the  fingers, 
Phalanges, 

Through  the  metacarpo-phalan- 
geal  articulation, 
Amputation  of  the  metacarpal 

bones, 
Amputation  at  the  wrist, 
Circular  method, 
Antero-posterior  flaps, 
External  lateral  flap, 
Amputation  of  the  forearm, 
Amputation  at  the  elbow-joint, 
Anterior  flap, 

(a)  The  joint   opened  from 

behind, 
(tf)  The  joint  opened  from 
in  front, 
Lateral  Map, 
Circular, 
Amputation  of  the  arm, 
Amputation  at  the  shoulder-joint, 
<  ieneral  considerations, 
Oval  method  (Baron  I.arrey), 
Double  flap  method  (Lisfrauc), 
Spence'e  method, 
Amputation  of  the  arm,  scapula,  and 

clavicle, 
Amputation  of  the  toes, 

Distal  phalanx  of  the  great  toe, 
Disarticulation  of  the  great  toe, 
Two  adjoining  toes, 

Amputation  of  a  metatarsal  b< 

Disarticulation  of  the  i>tor  5tb 
metatarsal, 
Disarticulation   of  all  the   metatar- 
sal bones  i  Lisfranc's  amputa- 
tion l, 
Modifications, 
tfedio-tarsal  amputations  (<  impart;, 


97 
100 


100 
101 


104 
105 
105 
105 
105 
106 


Sub-astragaloid  amputation, 

Tripier's  modification, 
Amputation  at  the  ankle-joint 
(Syme), 

Modifications, 

A.  Internal  lateral  flap 
(Koux), 

B.  Pirogoff's  amputation, 
Comparison  of  the  different  methods 

of  partial  and  total  amputation 
of  the  foot. 
Amputation  of  the  leg, 

A.  Lower  third, 

1.  Circular  method, 

Brun's 

2.  Modified  circular, 

3.  Long  anterior  flap  (Bell),  107 

4.  Elliptic  posterior  flap 
(Guyon),  107 

B.  Middle" third,  108 

1.  Long  anterior  curved  flap,  108 

2.  Single  posterior  flap,  108 

3.  Skin    flaps    and    circular 
division,  108 

C.  Upper  third,  109 

1.  Long  anterior  rectangular 
flap  (Teale),  109 

2.  Long  posterior  rectangu- 
lar flap  (Lee),  110 

:;.  Modified  flap  (Bell),  110 

Comparison  of  the  different  methods,  110 

Amputation  at  (he  knee,  ill 

A.  Disarticulation,  ill 

Lateral  Haps.  112 

B.  Amputation  througb  the 
condyles,  oval, 

Anterior  flap  (Car den  |, 
Oritti's  modification, 
Am|iiitai  ion  of  tin-  thigh, 
Teale  and  <  larden, 

Modified     flap,     in     lower  third 

(Syme),  116 

Long  anterior  flap,  1 16 

Circular,  117 

Amp  itation  at  the  bip-Joint,  1 18 

Anterior  racket  or  oval,  120 
External  racket  or  modified  oval,  121 

\  nterlor  flap,  122 

Senn'8  method.  123 


112 

112 

118 
115 
116 


C0N1ENTS. 


VI 1 


PART   IV. 


EXCISION   OF   JOINTS   AND   BONES. 


PAGE 

General  considerations,  125 

Major  articulations,  128 

Excision  of  the  shoulder-joint,  12$ 

Ollier's  method,  12!) 

Yon  Langenbeck's  method,  130 

By  a  transverse  incision,  131 

Excision  of  the  elbow-joint,  131 

Central  longitudinal  incision 

(v.  Langenbeck),  132 

Ollier's  method,  133 

Nelatou's  method,  134 

Long  radical  incision  (Hueter),    135 
Osteoplastic  method,  136 

Bilateral  incisions  (Vogt),  137 

Partial  excision,  137 

Excision  of  anchylosed  elbow,  137 

Ollier's  method,  138 

P.  Heron  Watson's  method,  138 

Operative  reduction  of  old  disloca- 
tion, 139 
Excision  of  the  wrist.  140 
Bilateral  incisions  (Lister),            141 
Radial  incision  (Oilier),  144 
Dorso-radial  incision  (von  Lan- 
genbeck), 145 
Excision  of  the  hip-joint,                       14B 
Savre's  method,'                                146 
Ollier's  method,                                 148 
Langenbeck,  148 
Anterior  incision,  149 
Arthrectomy,                                      150 
Anchylosis  of  the  hip-joint,  treated 
by   subcutaneous   division    of 
the  neck  of  the  femur  (Adams),  150 
Division  below  the  trochanter,       152 
Excision,                                             152 
Excision  of  the  knee-joint,  153 
Semilunar  incision,                           153 
Transverse  incision,  154 
Arthrectomy,  154 
Excision  of  the  ankle-joint,  155 
Vogt's  method  by  removal  of  the 

astragalus,  157 

Osteoplastic    excision     of    foot 
(Mikulicz),  15S 

Operative   reduction    of   old    Pott's 

fracture,  160 

Excision  of  the  bones  and  smaller 

articulations,  161 

Excision  of  the  superior  maxilla,  161 
Operation  by  a  median  incision,  163 
Subperiosteal  excision  (Oilier),  165 
Excision  of  lower  portion,  166 

Excision  of  upper  portion,  167 

Simultaneous   excision   of   both   su- 
perior maxilla?,  168 
Partial  and  temporary  excisions  of 
the  superior  maxilla  to  facili- 
tate    the     removal     of     naso- 
pharyngeal polyps,  168 
Osteoplastic    resection    of    an- 
terior portion  of  hard  palate 
(Chalot),  169 


PAGE 

Partial  resection  of  the  upper  por- 
tion (von  Langenbeck),  170 
Other  methods  of  gaining  access  to 

the  pharynx  through  the  nose,  171 


Boeckel, 

Oilier, 
Excision  of  the  inferior  maxilla, 

General  considerations, 

Resection  of  the  anterior  portion 
of  the  body, 

Resection  of  the  lateral  portion 
of  the  body, 

Resection  of  the  ramus  and  half 
the  body, 

Excision  of  the  entire  bone, 

Subperiosteal  method, 

Partial  excisions, 
Anchylosis  of  the  jaw, 

Excision  of  the  condyle, 
Resection  of  the  sternum, 
Resection  of  the  ribs, 

Estlander's  operation  for  empy- 
ema, 
Excision  of  the  clavicle, 
Excision  of  the  scapula, 

Subperiosteal  method  (Oilier), 

I  Opening  of  the  joint 


171 
173 
173 
173 


176 

177 
178 
178 
178 
178 
179 
180 
180 

180 

181 

182 

183 

185 

Partial  excisions  of  the  scapula,    185 

Resection  of  the  humerus,  185 

Upper  portion,  185 

Middle  portion,  186 

Lower  portion,  186 

Total  excision,  186 

Excision  of  the  ulna,  186 

Excision  of  the  radius,  186 

Partial  excisions  of  the  ulna  and 

radius,  187 

Excision   of   the    metacarpal  bones 

and  phalanges,  187 

Resection  of  a  phalanx,  1S7 

Resection  of  the  bones  of  the  pel- 
vis, 188 
Excision  of  the  coccyx,  188 
Resection   of   the   shaft    of   the    fe- 
mur.                                                        189 
Resection  of  the  shaft  of  the  tibia,      189 
Resection  of  the  fibula,  190 
Of  its  upper  extremity,  191 
( If  the  lower  portion,                         191 
Excision  of  the  entire  fibula,  192 
Excision  of  the  bones  of  the  foot,        192 
Calcaneum,                                          192 
Subperiosteal     method    (Oi- 
lier),                                        192 
Farabeuf,                                      193 
Astragalus,                                          194 
Ollier's  method,                          194 
When  dislocated,  195 
When  shattered,  195 
Metatarsal  bones  and  phalanges,  195 
Operations  upon  the  cranium,  195 
Trephining,  195 
Trephine,                                          195 


VI 11 


CONTENTS. 


Trephining — 
Chisel, 

Gigli  saw. 

Temporary .  bj  omega  Hap, 

Craniectomy, 

In  fracture, 

Relation    of    brain   to  overlying 

parts  I  Reid), 
Relation  of  brain   lo   overlying 

parts  (Kocher), 
Position  of  lateral  sinus, 
To  open  lateral  sinus, 


J.OE 

PAGE 

Trephining— 

196 

I'm-  cerebral  abscess  due  t<i  mid- 

107 

dle-ear  disease,                          208 

1  Hit 

Of  cerebellum.                                  210 

200 

Puncture  of  lateral  ventricles,       210 

200 

For   middle  meningeal   hemor- 

rhages,                                          211 

•jiiu 

Resection  of  fifth  nerve  within 

the  skull,                                     213 

204 

Of  the  frontal  sinus,                          21:; 

207 

207 

Of  the  antrum,                                 213 

PART    V. 


SKI  IIOTOMV,   TENOTOMY,   OSTEOTOMY,     \SI>    MISCELLANEOUS 
OPERATIONS. 


Division  and  resection  of  nerves. 
Supra-orbital  nerve. 

Subcutaneous  division, 

Excision  of  a  port  ion, 

A.  Above  the  eyebrow, 

B.  Below  the  eyebrow, 
Snpra-trochlear  nerve, 

8  ipei  ior  maxillary  nerve, 

A.  Division  of  the  nerve  on  the 

face, 

1.  Subcutaneously, 

2.  Through  the  mouth, 
:i.  By  external  excision, 

B.  le  -eel  inn   of    the    i  II  lYa-nl'l  li  I  al 

portion, 
TDlau  \-  method, 
LUcke'a  method, 
inferior  dental  nerve, 

A.   Al  the  mental  foramen, 

p..  win. in  the  canal, 
i      Bi  tore    lu    entry    into  the 
canal, 

1.  Prom  within  the  ne. iilli, 

2.  Through  the  ohi  el  . 
Ai  the  foramen  "••  ale, 

Buccal  oerve, 
Lingual  nerve, 

Moore'  -  in.  thod, 
Facial  nerve, 
Brachial  plexus, 

Cen  leal  plexus. 


215 

Spinal  accessory, 

226 

215 

First,  second,  and  third  nerves 

for 

•_'!.; 

wry-neck, 

227 

216 

Median  nerve, 

228 

216 

Ulnar  nerve, 

228 

217 

Musculo-spiral  uerve, 

229 

217 

Great  sciatic  nerve, 

229 

217 

1  ni. -nial  popliteal  nerve, 

229 

External  popliteal  nerve, 

220 

218 

Anterior  crural  nerve, 

220 

218 

Neurorrhaphy, 

280 

21 S 

Tenotomy, 

2:to 

218 

I  leneral  considerations, 

230 

Tendo-Achillia, 

231 

218 

l  ibialis  post  icus, 

231 

218 

\.    Lbove  the  malleolus, 

231 

21 '.I 

it.  On  the  Bide  of  the  fool 

232 

220 

Tibialis  anticus, 

282 

220 

Peronei, 

282 

2211 

1  lexer  lemh.n-  al  the  tc 1, 

282 

Sterno-eleido-mastoid, 

282 

221 

Tenorrhaphy, 

232 

221 

i  >f  teotomj . 

221 

Shaft, 

286 

222 

lei 

286 

22:; 

Supra-condyloid, 

286 

22 1 

i  or  hallux  \ algus. 

286 

22  1 

i  uneifoi  m,  tor  talipes, 
i  Operations  for  ununited  fracture 

287 

22.". 

210 

22.-. 

Suture  of  patella, 

211 

220 

.  ii.  .i  anon, 

242 

221'. 

Laminectomy, 

242 

Ml-(  l.l.l,  Wl.oi  s  OPER  mONS. 


II  inc. 

Separation  of  web-fli 

:>  Lai  flex  Ion  oi  phaianget 


2  1 8      I  mpiiylren's  coni  raei  inn, 

248    i  n grown  toenail. 

246    Remot al  of  ceri leal  glands, 


217 
217 
248 


CONTENTS. 


IX 


PART   VI. 


PLASTIC  OPERATIONS  ON   THE   FACE. 


TAGE 

The   dift'erent   methods    and     then- 
history,  251 
General  principles,  25Z 
Cheiloplasty,  «» 
A.  Lower  lip,                                   2o3 

1.  V-incision,  253 

2.  Oval  horizontal  incision,     253 

3.  Method  of  Celsus  or  Serres,  254 

4.  Dieffenbach,  255 
5   Syme-Buchanan,  255 

6.  Buck's  method,  257 

7.  Square  lateral  Haps,  Mal- 
gaigne,  258 

8.  Square  vertical  Haps,  259 
B   Angle  >>f  the  mouth  (stomato- 
plasty), 260 

Buck,  200 

C.  Upper  lip,  262 

1.  Vertical  flaps,  262 

2.  Infero-lateral  flap,  262 
Harelip,  263 

Single  harelip,  simple,  263 

1.  Double  flaps,  264 

2.  Nelaton'a  method,  265 
:■•,.  Single  Bap,  265 
4.   Gir aides' S  method,  265 

Double  harelip,  simple,  266 

Complicated  harelip,  267 

Rhinoplasty,  268 

1.  Superficial  defect,  not  involv- 

ing the  bones  or  septum,  269 
Lateral,  oblique,  and  vertical 

Haps,  269 

Denonvillier's  method,  270 

Von  Langenbeck's  method,  270 
Michon's  method,  271 

Restoration  of  columna,  271 

2.  Loss  of  the  septum  and  nasal 

bones,  the  skin  remaining 
entire,  272 

Dieifenbach's  ease,  272 

Ollier's  osteoplastic  method,  273 
Double  layer,  or  superposed 

flaps,      '  274 

Pancoast's  subcutaneous  me- 
thod, 275 

3.  Loss  of  more  or  less  of  the  sur- 

face and  the  septum,  276 

A.  Indian  method,  276 

Modifications,  277 


PAGE 

Rhinoplasty— 

B.  Ollier's  osteoplastic  me- 
thod. 279 

C.  Alquie's  method,  281 

D.  Italian  method,  281 
Operations  upon  the  eyelids,  282 

Blepharorrhaphy,  282 

Canthoplasty,  283 

Blepharoplasty,  284 

1.  In  ectropion,  284 

Wharton  Jones,  284 

Aiphonse  Guerin,  284 

Von  Graefe,  285 

Dieffenbach,  Adams,  and 

Amnion,  2s.i 

Richet,  286 

Knapp,  287 

Burow,  287 

Dieffenbach,  288 

Indian  method,  288 

Richet,  289 

Ilasner  d'Artha,  289 

Denonvillier,  290 

Ectropion  due  to  excess 

of  conjunctiva,  291 

2.  Entropion,  291 
Canthoplasty, 

Ligature,  .       291 

Excision  or  cauterization 

of  a  fold  of  the  skin,  291 
Spasmodic       entropion, 

Von  Graefe,  292 
Division  of  tarsal  carti- 
lage, 293 
Vertical  division,  293 
Longitudinal      divi- 
sion (Amnion),  293 
Excision  of  part  of  tarsal 
cartilage,  298 

3.  Symblepharon,  294 
Ligature,  294 
Arlt's  method,  294 
Teale's  method,  295 
Ledentu's  method,  295 

4.  Pterygion,  296 
Excision,  296 
Ligature,  296 

5.  Trichiasis,  297 
Von  Graefe,  297 
Anagnostakis,  297 


CONTENTS. 
PART   VII. 

SPECIAL   OPERATIONS. 


CHAPTER   I. 

OPERATIONS   UPON    THE   EYE   AND   ITS   APPENDAGES. 


PAGE 
299 
299 
301 
301 
302 
302 


The  cornea, 

Removal  of  a  foreign  body, 
Puncture  of  the  cornea. 
Evisceration  for  staphyloma, 
The  iris, 

Iridotomy, 

Simple  incision   (Cheselden, 

Bowman),  302 

Simple  iridotomy,  Wecker,     303 

Double  iridotomy,  Wecker,     303 

Iridectomy,  308 

Antiphlogistic  iridectomy,      304 

Iridesis,  307 

Corelysis,  308 

Operations  undertaken  for  the  relief 

of  cataract,  309 

Depression  or  couching,  310 

Scleronyxis,  310 

Keratonyxis,  311 

Division,  Discission,  or  Solution,  311 
Division  through  the  cornea,  312 
Division  through  the  scle- 
rotic (Havs),  312 
Ex  1  raft  ion,  313 
Flap  extraction,  313 
Von  Graefe's  method,  317 


its 


PAGE 

Operations  undertaken  for  the  relief 
of  cataract — 
Gayett  and  Knap]., 
Linear  extraction, 
Scoop  extraction. 
Removal  by  suction, 
Removal  of  the  lens  in 
capsule, 
Pagenstecher'e  method, 
Secondary  cataract, 
Operations  for  the  relief  of  strahis- 
mu8, 
Internal  rectus, 
Subconjunctival  method, 
Secondary  strabismus, 
Enucleation  of  the  eyeball, 

Extirpation  of  the  contents  of 
theorbit,  329 

Operations  upon  the  lachrymal  ap- 
paratus, 329 
Extirpation    of    the    lachrymal 

gland,  329 

Lachrymal  sac,  duct,  and  canal- 

iculi,  380 

Slitting  up  the  canaliculus.     :'.:il 
Puncture  of  the  sac,  '■'<*■! 


820 
320 
321 

322 

323 
824 
824 

826 
326 
327 
328 


CHAPTER  II. 

OPERATIONS   UPON    THE    BAB    AND   ITS  APPENDAGES. 

Occlusion  of  the  external  auditory  Catheterization    of    the    Eustachian 

canal,  :;:;|       tube,  335 

Introduction  of  speculum,  334    Opening  of  mastoid  antrum,  886 

Paracentesis  of  the  drum-head,  334  | 

CHAPTER   III. 

OPERATIONS   UPON    THE   MOUTH   AND    PHARYNX. 


Excision  "i  the  tonsils,  337 

Staphylorrhaphy,  338 

Qranoplasty,  345 

isson'e  osteoplastic  method,  :;is 

Dai  lee-Colley's  method,  848 

Excision  ol  the  tongue,  849 

l  hrougb  the  mouth,  350 

Kocher,  352 


Excision  of  the  tongue— 
x'dil  lot's  method, 

Division  of  the  fraeuum, 

Kami  ht, 

Salivary  fistula, 

i  leguise's  method, 
Van  Buren'e  method, 


CHAPTER  IV. 
.,11  BATIOME    PI  l:10RMED  UPON  THE  NECK. 


Bronchotomy,  357 

Subhyoid  laryngotomy,  867 

old  laryngotomy, 

.-thyroid  laryngotomy,  B69 

Laryngo-tracheotomy.  860 

hi  <  lermaln's  method,  881 

Tracheotomy,  B61 

By  galvano-  or  thermo-cau- 

tery,  •"',;:; 


tomy, 
i  omplete, 
Partial, 
Pharyngotomy, 

\  ..I.  I  .angenbeck, 
Mikulicz, 

Cheever, 

i  Esophagotomy, 

i  aternal, 


353 
355 
355 
355 
866 
356 


364 
364 
365 
366 
866 
367 
368 
368 
369 


CONTENTS. 


CEsophagotoiny — 

External,  370 

Operations  upon  thyroid  gland,  371 

Ligation  of  arteries,  373 


Operation  upon  thyroid  gland— 

Enucleation  of  a  portion,  374 

Removal  of  a  portion,  374 

Removal  of  isthmus,  375 


CHAPTER  V. 


OPERATIONS   PERFORMED   UPON  THE   THORAX. 


Amputation  of  the  breast, 
Halsted, 


376    Paracentesis  of  the  thorax, 

376    Paracentesis  of  the  pericardium, 


377 
378 


CHAPTER   VI. 

OPERATIONS   PERFORMED   UPON  THE  ABDOMINAL  WALL, 
STOMACH,   AND   INTESTINES. 


Paracentesis  of  the  abdomen, 
Laparotomy, 

Operations  on  the  intestines, 
Anatomy, 
Continuous  suture, 
Right-angled  continuous, 
Interrupted  (Lembert), 
Czerny, 

Halsted's  quilt  suture, 
Circular  euterorrhaphy, 
Intestinal  anastomosis, 
Senn's  plates, 
Murphy's  button, 
By  intussusception, 
Enterostomy, 

Right  inguinal, 
Colostomy, 

Right  inguinal, 
Lumbar, 
Closure  of  an  artificial  anus  or 

fecal  fistula, 
Removal  of  vermiform  appendix, 
McBuruey, 

During  period  of  suppura- 
tion, 
Stomach, 

Gastrostomy, 

Kader, 
Gastrotomy, 

For    stenosis   of   pyloric    or 
cardiac  orifice, 
Gastrorrhaphy, 
Gastroplication, 
Pylorectomy, 
(instroenterostomy, 
Jejanostomy, 
Herniotomy,  kelotomy, 
General  directions", 

A.  Recognition  of  the  sac  and 
bowel, 

B.  Opening  of  the  sac, 

C.  Division  of  the  stricture, 

D.  Examination  and  return 
of  the  bowel, 

E.  Treatment  of  the  omen- 
tum, 


379 

Herniotomy,  kelotomy — 

380 

Strangulated  inguinal  hernia, 

426 

383 

Femoral  hernia, 

428 

383 

Fmbilical  hernia, 

430 

385 

Obturator  hernia, 

432 

386 

Radical  cure  of  inguinal  hernia, 

432 

386 

Czerny, 

432 

:;ss 

Bassini, 

434 

388 

Halsted, 

439 

:-;ss 

MeBurney, 

439 

390 

Radical  cure  of  umbilical  hernia 

440 

393 

Radical  cure  of  femoral  hernia, 

440 

393 

Operations  upon  the  rectum, 

441 

394 

Imperforate  anus  or  rectum, 

442 

395 

Prolapse, 

444 

395 

Rectopexy, 

446 

397 

Ablation, 

446 

398 

Torsion, 

447 

399 

Rectotomy, 

447 

Fistula, 

447 

401 

Hemorrhoids, 

448 

402 

Ligation, 

448 

404 

Whitehead, 
Excision  of  anus  and  part  of  rec- 

448 

404 

tum, 

449 

405 

A.     Removal  from  below, 

449 

407 

B.     Removal     from     below 

409 

leaving  sphincter, 

451 

411 

C.  Hueter's  method, 

D.  Removal    from    behind 

452 

412 

Kraske, 

453 

414 

Liver, 

456 

415 

Abscess, 

457 

416 

Hydatids, 

459 

418 

Cholecystostomy, 

460 

421 

Operations  on  bile  ducts, 

461 

421 

Cholecystenterostomy. 

462 

422 

Cholecystectomy, 

464 

Spleen, 

464 

422 

Splenectomy, 

465 

423 

Kidney, 

465 

424 

Exposure  of, 

466 

Lnmbai  methods, 

466 

425 

Nephrotomy, 

469 

Nephrolithotomy, 

469 

426 

Lumbar  nephrectomy, 

471 

CONTENTS. 


Kidney— 

Abdominal  nephrectomy , 
Nephropexy, 


PAGE 

I  Ureter, 
•172  Operations  on, 

474  Wounds  of, 


PAGE 

474 
475 

477 


CHAPTER   VII. 


OPERATIONS   UPON   THE  GENITO-URINAUY   ORGANS   OF   THE    MALE. 


(  last  ration, 

Hydrocele, 

Puncture  of  the  sac, 

Radical  cure, 
Varicocele, 

Excision  of  the  scrotum, 

Subcutaneous  ligature, 

Open  ligation, 
Amputation  of  the  penis, 
Operations  for  phimosis, 

Dorsal  incision, 

Circumcision, 
Paraphimosis, 
Division  of  the  fraenuin, 
Epispadias, 

Nrlaton's  method, 

Thiersch's  method, 
Hypospadias, 

Urethroplasty, 

i  ln'opliili-  A  user's  method, 

I  >u  play's  method, 
Urethral  fistula, 

( leneral  considerations, 

Urethrorrhaphy, 

Urethroplasty, 

Nrlaton's  me!  hod. 

Key bard,    Dieffenbach,    and 
Delore, 


■ISO 

Urethral  fistula — 

481 

Delpcch  and  Alliot, 

500 

481 

Sir  Astley  Cooper, 

500 

482 

Arlaud, 

500 

482 

Sedill.it, 

501 

482 

Rigaud, 

501 

483 

Theophile  Anger, 

501 

483 

Scynianowski, 

501 

484 

McBurney, 

501 

485 

Internal  urethrotomy, 

502 

485 

External  perineal  urethrotomy, 

503 

485 

A.  With  a  guide, 

503 

487 

B.  Without  a  guide, 

505 

487 

Exstrophy  of  the  bladder, 

507 

487 

Catheterization, 

509 

488 

Puncture  of  the  bladder, 

511 

490 

Litholapaxy, 

511 

492 

Lithotomy, 

51  fi 

403 

Lateral  lithotomy, 

517 

494 

Median  lithotomy, 

521 

49G 

Supra-pubic  lithotomy, 

523 

497 

Prostatectomy,  supra-pubic, 

52G 

497 

Perineal, 

527 

198 

Combined  supra-pubic  and  peri 

499 

ncal, 

527 

199 

Tumors  of  bladder, 

527 

Removal  of  seminal  resides, 

530 

CHAPTER   VIII. 


i.PKU  \Tlo\S    ri-nN    THE   GEXITO-rKIMARY    ORGANS   OF    THE    FEMALE. 


Catheterizal  ion, 

External  urethrotomy, 

Lithotomy, 

i Irethral  lithotomy, 
Veaico-vaginal  lithotomy, 

Occlusion,  or  at  resia  vaginas, 

P(  i  iiieorrhaphy , 

Prolapse  of  the  posterior  wall  ol  the 

vagina, 
1st  variety, 
2d   variety, 

Elegar's  method, 

Laceration      Of     the     perineum     and 

sphincter  ani. 

-\  aginal  fistula, 

[i  o-i  aginal  fist  ula. 
Obliteration  of  the  vagina:  kolpox- 

■.  Ing  of  i  be  vagina  ;   elj  i  ror- 
rtaaphy, 
Post*  i  rrbaphj    oi    colpop- 

i  baphj  ■  Hegar), 

Martin,' 

La<  •  rated  cervix, 


533 

588 
585 
585 
635 
586 
537 

538 

540 

oil 

548 

:.  19 
554 


557 

558 
659 


Posterior  section  of  the  cervix, 
Operations   on    the    uterus   and   ad- 
uexa, 

Anatomy, 

( Ovariotomy, 

Oophorectomy, 

Salpingo-ooplioroctomv, 

Tumors  beneath  broad  ligament, 

For  ectopic  gestal  ion, 

l  [ysteropexy, 

Intra-abdominal    shortening   <if 

broad  ligaments, 
Shortening       round        ligaments 

(Alexander). 

La  pa  rohy  sterol  only, 
Symphysiol y , 

m  j ectomy, 

Abdominal  by  sterectoniy, 

\nipiilal  ion  of  grai  id  uterus, 
Vaginal  hysterectomy, 
Ampulal  ion  of  rervi  \, 

supra-vaginal, 

Re \  al  ol    mucosa  of  eci  \  ix, 


562 
562 

56 1 
566 
567 
569 

57(1 
571 


579 
580 
681 
582 


OPERATIVE  SURGERY. 


PART  I. 

THE   ACCESSORIES  OF   AN    OPERATION 


ANESTHESIA. 

Local  Anaesthesia  may  be  obtained  by  the  action  of  cold, 
or  by  the  application  of  an  agent  which  exerts  locally 
a  benumbing  effect  upon  the  nerves. 

Cold. — The  skin  can  be  chilled  by  the  application  of 
ice  or  by  a  spray  of  any  substance  that  evaporates  rap- 
idly, lee  acts  most  efficiently  when  finely  broken  and 
mixed  with  salt  ;  it  is  conveniently  applied  in  a  muslin 
bag,  and  the  application  should  be  maintained  until  the 
skin  has  become  white  or  until  testing  shows  it  to  be 
insensitive. 

For  chilling  by  rapid  evaporation  ethyl  chloride  is  in 
most  common  use.  It  is  supplied  under  the  name  of 
"ethylene,"  in  small  glass  tubes  from  which  it  is  allowed 
to  escape  in  a  tine  jet  which  can  be  accurately  directed 
upon  the  part  to  be  chilled.  Ether  thrown  upon  the  skin 
from  an  atomizer  is  moderately  effective. 

Carbolic  Acid  is  a  fairly  efficient  and  convenient  means 
of  producing  local  anaesthesia.  A  cloth  thoroughly  Met 
with  a  3  per  cent,  solution  of  the  acid  is  kept  upon  the 
skin  for  fifteen  minutes,  and  then  the  undiluted  acid  ap- 
plied with  a  brush  along  the  line  of  the  proposed  incision. 

Cocaine. — This  is  used  in  the  form  of  a  one  to  four  per 
cent,  solution  injected  into  or  beneath  the  skin  or  into  or 
•J  17 


I>  ////:   ACCESSORIES   OF  AS   OPERATION. 

about  the  trunk  of  a  nerve.  As  it  is  dangerously  toxic 
only  small  quantities  should  be  used.  When  the  skin  is 
uninflamed  the  best  method   is  to  insert  a   hypodermic 

needle  very  obliquely  into  the  skin  and  force  a  lew  drops 
of  the  solution  through  it;  the  needle  can  then  be  ad- 
vanced painlessly  along  the  welt  raised  by  the  injection, 
and  additional  drops  injected  until  the  needle  has  been 
introduced  to  its  full  length.  It  is  then  withdrawn  and 
inserted  afresh  at  the  furthest  point  reached  by  the  injec- 
tions until  the  entire  distance  to  be  occupied  by  the  in- 
cision has  been  rendered  insensitive.  The  action  of  the 
drug  is  hastened  and  prolonged,  and  the  chance  of  poi- 
soning diminished,  by  temporarily  cutting  off  the  blood- 
supply  from  the  part ;  in  the  case  of  a  limb  this  is  most 
conveniently  done  by  circular  elastic  constriction. 

Injection  into  inflamed  parts  is  very  painful  because  of 
the  increased  tension,  and  it  is,  therefore,  better  in  such 
cases  to  seek  to  benumb  the  nerves  supplying  the  part  by 
injection  beneath  the  skin  on  the  proximal  side  of  the  pro- 
posed incision. 

General  Anaesthesia. — The  agents  in  common  use  for 
producing  general  amesthesia  are  ether,  chloroform,  and 
nitrous  oxide. 

The  great  advantage  of  ether  is  in  its  safety.  Chloro- 
form is  more  rapid  in  its  action  and  more  easily  taken, 
hut  it  is  distinctly  more  liable  to  cause  death  during  its 
administration.  On  the  other  hand,  ether  acts  unfavor- 
ably upon  kidneys  that  are  already  diseased,  and  it 
is  not  well  borne  by  the  elderly  with  chronic  pulmonary 
complications.  Its  vapor  is  inflammable;  that  of  chloro- 
form is  not. 

Hither  agent  may  cause  death  by  suffocation,  through 
obstruction  of  the  air  passages  by  the  relaxed  and  de- 
pendent tongue  or  by  the  lodgment  of  vomited  matter; 
but  chloroform  may  also  kill  by  specific  action  upon  the 
respiratory  and  circulatory  centers. 

The  indication  when  suffocation  threatens  and  the  face 
i-  blue  and  swollen  18  to  clear  the  air  passages,  usually  by 
drawing  the  tongue  forward  or  by  pressing  the  lower   jaw 


ANESTHESIA.  19 

forward  with  the  fingers  placed  below  and  behind  its 
angles.  If  vomited  matter  or  other  foreign  body  has 
lodged  over  or  within  the  larynx  the  patient  should  be  so 
placed  that  his  head  and  shoulders  are  dependent  and 
should  then  be  forcibly  shaken. 

Death  by  the  toxic  action  of  chloroform  comes  in  the 
form  of  syncope  with  a  pale  face,  and  sometimes  after 
only  a  small  quantity  has  been  given,  one  or  two 
drachms.  This  sudden  early  poisoning  is  best  guarded 
against  bv  intermitting  the  administration  whenever  the 
patient  struggles  and  not  renewing  it  until  after  he  has 
taken  at  least  one  full  breath.  The  condition  is  to  be 
met  by  suspending  the  patient  head  downward  and 
practicing  artificial  respiration. 

Administration  of  the  Anaesthetic. — Chloroform  is  best 
given  by  letting  it  fall  drop  by  drop  upon  a  single  layer 
of  muslin  stretched  upon  a  small  wire  frame  and  held 
close  over  the  mouth  and  nostrils.  This  is  thought  to  be 
somewhat  safer  than  pouring  a  drachm  or  two  upon  a 
handkerchief  and  renewing  it  as  it  evaporates. 

Ether  is  commonly  given  from  a  "  cone "  made  by 
wrapping  a  towel  about  several  thicknesses  of  paper 
folded  in  a  strip  about  eight  inches  wide  and  one  and 
a-half  or  two  feet  long,  and  then  folding  it  again  into  a  roll 
which  will  fit  snugly  over  the  chin  and  nose.  The 
upper  end  of  the  roll  should  bo  elosed  by  pinning  its 
edges  together,  and  a  handkerchief  or  bunch  of  absorbent 
cotton  should  be  pressed  into  it  that  it  may  retain  a 
larger  amount  of  the  ether. 

Special  apparatuses  composed  of  a  rubber  bag  and  a 
mouthpiece  and  receptacle  which  permits  the  admixture  of 
air  with  the  ether  vapor  in  any  desired  proportion  are  in 
quite  common  use  in  hospitals  and  have  many  advantages. 

The  method  recently  introduced  by  Dr.  Thos.  L.  Bennett 
of  first  producing  insensibility  by  nitrous  oxide  and  then 
continuing  with  ether  has  removed  the  discomforts  and 
inconveniences  which  made  the  preliminary  stage  of 
etherization  so  disagreeable  for  both  the  patient  and  the 
surgeon. 


20  THE  ACCESSORIES  OF  AN  OPERATION. 

Rectal  Etherization.  —  It  was  shown  by  Molliere,  in 
1884,  that  genera]  anaesthesia  could  be  readily  obtained 
by  the  administration  of  ether  by  the  rectum.  The 
method  was  at  once  widely  tried,  but  has  been  abandoned, 
except  in  special  cases,  for  it  was  found  to  be  more  dan- 
gerous than  the  method  by  inhalation.  The  dangers  are 
that  the  anesthetization  may  unwittingly  be  made  too 
profound  and  prolonged,  and  that  the  contact  of  the  ether 
with  the  intestinal  mucous  membrane  may  cause  a  bloody 
diarrhoea. 

The  ether  is  placed  in  a  bottle  provided  with  a  tightly- 
fitting  cork  through  which  passes  a  rubber  tube.  The  free 
end  of  the  tube  is  inserted  in  the  rectum,  and  the  bottle 
placed  in  warm  water. 

The  precautions  to  be  observed  are  that  the  water 
should  not  be  warmer  than  100°  Fahr.,  and  that  as  soon 
as  anaesthesia  is  obtained  the  tube  should  be  withdrawn 
from  the  rectum,  to  be  reapplied  if  necessary.  The  tube 
should  be  large,  and  should  extend  downward  from  the 
anus  to  the  bottle  without  loops  or  coils  in  which  the 
ether  might  condense. 

ARREST  OF  HEMORRHAGE. 

Hemorrhage  is  arrested:  by  ligature;    by  torsion;  by 

pressure  ;   by  cold  or  heat  ;  by  position. 

Ligature. — The  vessel  or  I  deeding  point  is  seized  by  for- 
ceps (Figs.  1,  -  and  •'!)  with  as  little  of  the  surrounding 
tissue  as  possible.  It  is  encircled  by  silk  or  catgut,  which 
is  tied  in  a  square  knot  (Fig.  1).  <  >r,  if  the  vessel  can- 
not be  seized  or  held,  the  ligature  is  passed  under  it  on  a 
curved  needle. 

Torsion. — Thevessel  is  isolated,  grasped  by  the  forceps, 
drawn  out  and  twisted  till  it  parts.  It  is  not  in  general 
USe  except    for  small   vessels. 

Pressure  made  by  sponges,  gauze  pads,  or  clamps  left 
in  place  for  a  lew-  minutes  will  frequently  be  found  suffi- 
cient to  arresl  oozing,  venous  hemorrhage, or  the  bleeding 
from  small  arteries. 


ARREST  OF  HEMORRHAGE. 


21 


Fig.  l. 


Artery  forceps. 


Fig.  2. 


Self-holding  hemostatic  forceps. 


Fig.  3. 


Self-holding  haemostatic  forceps;  curved. 


22 


THE   .\r<  i;\sni; I i;s   or  .|.\    OPERATION. 


Very  great,  crushing  pressure  by  :>  specially  con- 
structed instrument  (Fig.  5)  has  been  successfully  used 
and  of  late  even  to  secure  vessels  as  large  as  the  femoral 
artery.     It  has  thus  far  been  used  almost  exclusively  in 

Fig.  4. 


quarc  knot. 


vaginal  hysterectomy  and  its  use  has  been   followed   in   a 

rather  large  proportion  of  cases  by  late  bleeding. 

Cold  or  Heat. — Hemorrhage  may  he  checked  by  the 
actual  cautery  at  a  dull-red  heat,  by  ice-cold  water  or  by 
water  at  a  temperature  of  110°  to  120°  F. 


Fig. 


Angiol  ribi 


Position,  either  alone  or  combined  with  pressure,  is  a 
valuable  haemostatic.  Elevation  of  a  limb  will  diminish 
the  blood  pressure  and  often  allow  a  coagulum  lo  form 
in  a  divided  vessel,  where  it  would  otherwise  be  washed 
away  by  the  force  of  the  blood  flow. 


ARTIFICIAL    TSCHJEMIA. 


23 


ARTIFICIAL    ISCHEMIA. 

Loss  of  blood  during  ;ui  operation  upon  a  limb  may  be 
prevented  by  pressure  upon  the  main  artery  on  the  proxi- 
mal side  of  the  incision.  This  pressure  may  be  made 
with  the  finger,  tourniquet,  or  elastic  cord. 

The  tourniquet  (Fig.  (i)  is  composed  of  a  pad,  band, 
and  screw  ;  by  turning  the  screw  the  band  may  be  tight- 
ened at  will.     The  principle  of  its  application  is  the  com- 

Fig.  (i. 


Petit's  tourniquet. 

pression  of  the  artery  against  the  underlying  bone.  A 
point  should  be  selected  in  the  course  of  the  artery  where 
such  compression  can  be  made ;  a  roller  bandage,  an  inch 
in  diameter,  placed  over  the  vessel  and  parallel  to  its 
course,  the  tourniquet  then  applied  as  shown  in  Figs. 
7  and  8  and  the  screw  tightened.  Some  surgeons  prefer 
to  place  the  pad  of  the  tourniquet  upon  the  roller  bandage 
itself  and  not  on  one  side  as  shown  in  the  figure.     The 


24 


THE   .U'CKSSOUIKX   <>F  AX   OPERATION. 


buckle  <>n  (ho  band  should  always  be  much   further  front 
the  roller  than  is  represented  in  the  figures. 

The  elastic  tourniquet  is  applied  after  holding  the  limb 
till-  ;i  short  time  in  an  elevated  position  to  diminish  the 
amount  of  blood  in  it.  Then,  without  changing-  the  posi- 
tion, a  soft  but  stout  rubber  cord  or  band  is  wrapped  sev- 
eral times  about  the  limb  sufficiently  tight  to  occlude  all 
the   vessels    and    fastened    in   position  by  a  single  knot. 


Fig.  7. 


Fig.  8. 


if  application  of  tourniquet. 


It    should    be   applied    :it  -a    eon venieiit    point,  well    above 

the  seal  of  operation.     Or  the   Esmarch  rubber  bandage, 

usually  two  or  more  inches  broad,  is  applied  from  the  fin- 
gers or  toes  of  an   extremity  spirally  upward,  each    upper 

turn  overlapping  the  one  below  from  a  quarter  to  half  an 
inch.  It  is  wound  tightly  enough  completely  to  empty 
all  the  vessels  of  blood  a-  it  advances  and  i-  carried  to 
the  point   where  the  rubber  tourniquet  can   be  best  ap- 


SUTURES. 


or, 


plied,   which    is    then   done  as   already  described.     The 
spiral  bandage  is  then  removed. 

The  objections  to  the  rubber  bandage  and  tourniquet 
are  the  possibility  of  pressure  paralysis  and  the  certainty 
of  temporary  vasomotor  paralysis,  with  its  consequent 
troublesome  oozing.  The  advantages  are  that  an  opera- 
tion can  be  performed  upon  the  living  body  with  as  much 
ease  and  accuracy  as  upon  the  cadaver.  It  is  very  useful 
whenever  careful  dissection  is  necessarv. 


SUTURES. 

The  continuous  suture  (Fig.  9)  is  passed  in  the  same 
manner  as  the  interrupted,  but  the  stitches  are  not  cut 
apart  and  tied.     It  is  conveniently  fastened  at  the  last  by 

Fui.  9. 


Continuous  suture. 


drawing  it  double  through  the  last  puncture  and  using  the 
free  end  to  make  a  knot  with  the  double  part  attached  to 
the  needle. 

Fig.  in. 


r>^ 


Twisted  suture. 


The  twisted  or  figure-of-8  suture  (Fig.  12)  is  made  bv 
transfixing  the  lips  of  the  incision  with  a  pin,  about  the 
two  ends  of  which  a  thread  is  then  twisted  (Fig.  10). 

Tension  or  relaxation  suture  is  the  name  given  to  one 


26  THE  ACCESSORIES  OF  AN  OPERATION. 

employed  to  relieve  strain  on  the  sutures  approximating 
the  edges  of  the  wound.  The  points  of  entry  and  emer- 
gence should  be  at  a  considerable  distance  from  the  in- 
cision. The  thread  is  passed  double,  and  in  order  to  lessen 
the  tension  at  any  one  point  its  extremities  are  tied  over 
buttons  or  plates  of  lead  or  pads  of  gauze. 

PREPARATION    OF    MATERIALS    USED    IN    AN 
OPERATION. 

Catgut  ranges  from  the  smallest  size,  Xo.  1,  up  to  No. 
li.  It  is  first  soaked  in  ether  for  twenty-four  hours  to 
free  it  from  fat,  then  wound  on  glass  spools  which  have 
been  recently  boiled.  The  hands  which  do  the  winding 
must  be  thoroughly  scrubbed  and  disinfected,  and  during 
the  winding  the  catgut  must  touch  nothing  which  is  not 
surgically  clean.  The  catgut  is  then  boiled  in  alcohol  for 
one  hour,  and  stored  for  use  in  boiled  absolute  alcohol  in 
a  sterilized  glass  vessel.  The  spools  of  catgut  are  some- 
times soaked  for  twenty-four  hours  in  a  1  :  1000  aqueous 
solution  of  bichloride  of  mercury  before  boiling. 

Chromicized  catgut  is  made  by  soaking  for  twenty-four 
to  forty-eight  hours  200  parts  of  catgut  by  weight  in  a 
mixture  of  carbolic  acid,  200  parts,  boiled  water  2000 
parts  and  chromic  acid  i  part.  It  is  then  boiled  in  alco- 
hol and  stored  in  boiled  absolute  alcohol. 

Silk  i>  used  in  sizes  from  the  smallest,  No.  I,  to  No. 
18,  the  sizes  mosl  convenienl  for  average  use  ranging 
from  7  to  10.  It  is  wound  on  sterilized  spools,  boiled  in 
water   for    half  an    hour,   and    stored    in    boiled    absolute 

alcohol  in  a  sterilized  glass  vessel. 

Silkworm-gut  is  -imply  boiled  in  alcohol  for  one  hour, 
and  Stored  in  boiled    absolute  alcohol    in  ;i  sterilized   glass 

vessel. 

Sponges. — Ordinary  sponge-  are  prepared  as  follows: 
Decalcify  in  a  solution  of  one  volume  of  commercial  hy- 
drochloric acid  and  three  volumes  of  water.  Kxaniine 
each  sponge  separately  for  pieces  of  stone  or  coral,  which 
musl  b<-  cui  or  torn  out.     Then  wash  in  running  water  to 


PREPARATION  OF  MATERIALS.  '-'7 

remove  every  particle  of  sand.  Place  them  in  a  solution 
of  permanganate  of  potassium  of  a  strength  of  about  1  to 
16  of  water  till  they  are  stained  a  chestnut  brown. 
Wash  again  in  running  water  to  remove  the  excess  of 
permanganate.  Place  them  in  a  solution  of  hyposnlphide 
nt*  soda  and  oxalic  acid — about  3j  of  each  to  a  pint  of 
water,  and  stir  the  sponges  till  they  are  bleached.  Then 
wash  in  running  water  to  free  from  acid  and  precipitated 
sulphur.  Rinse  out  in  a  solution  of  sodium  bicarbonate 
— about  1  part  to  25  of  water.  This  neutralizes  any 
acid  and  renders  the  sponge  texture  more  absorbent. 
Wash  again  in  sterilized  water  and  store  in  a  1  :  20  car- 
bolic solution  or  in  a  two  per  cent,  solution  of  formal- 
dehyde. 

Simple  pads  of  sterilized  absorbent  gauze,  with  the 
margins  loosely  hemmed,  make  excellent  and  cheap 
sponges  ;  they  should  be  sterilized  by  steam  for  half  an 
hour  immediately  before  use. 

Absorbent  gauze  is  best  purchased  from  the  manufac- 
turers. It  should  be  cut  into  convenient  lengths  and 
sterilized  by  steam  for  half  an  hour  immediately  before  use. 

Bichloride  gauze  is  conveniently  made  by  wringing  out 
the  sterilized  absorbent  gauze  in  a  solution  of  bichloride 
of  mercury  1  part,  common  salt  1  part,  and  water  1000 
parts.  The  salt  prevents  the  bichloride  from  changing 
to  calomel.  It  can  then  be  sterilized  by  steam  and  kept 
in  a  sterilized  ti<rht-vessel. 

Iodoform  gauze. — Where  the  exact  proportion  of  iodo- 
form is  unimportant  it  can  be  made  as  follows  :  Sterilize  a 
strip  of  absorbent  gauze  and  the  hands  of  the  maker. 
Dissolve  about  3ij  of  castile  soap  in  3j  of  a  1  :  20  aqueous 
carbolic  solution.  Strain  this  through  a  piece  of  sterilized 
gauze  to  render  the  suds  clear,  and  boil  the  filtrate.  Mix 
this  filtrate  with  nearly  an  equal  part  of  iodoform  in  a 
sterilized  basin.  Again  sterilize  the  hands  and  wring  out 
the  strip  of  sterilized  gauze  in  this  mixture.  Store  in  a 
sterilized  tightly-covered  vessel  in  the  dark. 

The  iodoform  mixture  cannot  be  boiled  without  decom- 
posing the  iodoform.     The  soapsuds  cause  the  iodoform  to 


28  THE  ACCESSORIES   <>F  AS   OPERATloS. 

adhere  to  the  gauze.  The  basin  in  which  the  mixing  of 
the  gauze,  soapsuds,  and  iodoform  is  carried  out  must  be 
previously  cleaned  and  sterilized. 

Some  prefer  to  sterilize  the  prepared  gauze  by  steam  ; 
but  this  sometimes  decomposes  part  of  the  iodoform,  and 
the  iodine  thus  liberated  is  very  irritating  to  the  skin. 

Drainage  tubes  are  most  conveniently  made  of  ordinary 
rubber  tubing — the  red  is  the  best — or  of  glass.  These 
should  be  boiled  and  stored  in  boiled  alcohol  or  a  bichloride 
or  formaldehyde  solution,  and  immediately  before  use 
boiled  again. 

Absorbable  bone  drainage  tubes  are  sometimes  used. 
They  can  be  obtained  from  the  instrument  makers. 

Absorbent  cotton  is  best  purchased  of  the  manufactur- 
ers. This  and  plain  cotton  can  be  sterilized  by  dry  heat 
in  an  oven  at  300°  F.  maintained  for  half  an  hour. 

Rubber  tissue  is  prepared  by  washing  thoroughly  in  a 
1  :  20  aqueous  carbolic  solution  and  soap.  It  is  then 
washed  in  alcohol  and  stored  in  1  :  1000  bichloride  of 
mercury  solution. 

STERILIZATION. 

The  Arnold  steam  sterilizer  is  most  efficient  for  general 
sterilization.  It  is  so  constructed  that  the  steam  is  con- 
densed after  it  is  used  and  the  water  needs  only  infre- 
quent renewal.  Gowns,  dressings,  etc.,  should  be  ex- 
posed to  tin'  steam  for  from  half  an  hour  to  three  hours, 
according  to  the  compactness  of  the  bundle.  A  very 
serviceable  sterilizer  can  be  made  from  an  ordinary  as- 
paragus cooker — a  covered  tin  vessel  aboui  twice  as  long 

a-  it  i-  wide  mid  deep — furnished  with  a  removable  tray. 
[nstruraents,  which  rust  badly  when  exposed  t<>  -team. 
should  be  sterilized  by  boiling  in  water  to  which  about 
one  per  cent.  <»('  sodium  carbonate  has  been  added  (to  di- 
minish rusting)  and  should  be  used  from  trays  of  sterile 
water  or  a  weak  carbolic  solution.  Cutting  instruments, 
which  lose  their  altfc  under  boiling,  may  be  sterilized  by 
dry  heal  <>r  by  passing  through  a  flame  or  by  ;i  brief  ex- 
posure ton  niir  or  two  per  cent,  formaldehyde  solution. 


WOUND  MADE  AND   ITS   TREATMENT.  29 

THE    WOUND    MADE    BY    THE    SURGEON    AND    ITS 
TREATMENT. 

The  secret  of  success  in  operative  surgery  lies  in  abso- 
lute cleanliness  of  the  operator  and  his  assistants,  the 
wound  and  its  surrounding  parts,  and  of  all  instruments, 
dressings,  and  accessories  which  come  directly  or  indirectly 
into  contact  with  the  wound. 

On  the  morning  of  the  day  before  the  operation  the 
skin  should  be  washed  and  scrubbed  with  green  soap, 
shaved  it  necessary,  and  sponged  off  with  a  1  :  1000  solu- 
tion of  bichloride  of  mercury.  It  is  then  spread  with  a 
layer  of  green  soap,  and  covered  with  compresses  saturated 
in  the  same  material.  Over  this  is  placed  a  piece  of 
rubber  tissue  to  prevent  drying,  and  the  "  soap  poultice  " 
is  left  in  place  till  the  evening  before  the  operation,  or  for 
about  twelve  hours.  It  is  then  removed,  and  the  area 
washed  carefully  with  a  1  :  1000  bichloride  solution,  and 
a  wret  1  :  5000  bichloride  dressing  applied  and  not  removed 
till  the  patient  is  on  the  table — at  least  twelve  hours 
later.  The  surface  is  then  washed  with  ether,  and  again 
with  the  1  :  1000  bichloride  solution.  The  surgeon,  his 
assistants,  and  any  attendants  in  the  operating  room  should 
have  their  arms  bare  to  the  elbow,  and  wear  sterilized 
gowns  reaching  to  the  feet.  All  these  persons  must  thor- 
oughly scrub  with  a  sterilized  brush,  green  soap,  and  hot 
water  their  arms,  hands,  and  finger-nails.  Then  clean 
the  finger-nails  with  a  clean  instrument,  and  wash  again 
with  chloride  of  lime  and  sodium  carbonate  (washing 
powder).  Then  soak  hands  and  arms  in  1  :  1000  bichlo- 
ride of  mercury.  It  is  still  better  to  use  rubber  gloves, 
sterilized  by  boiling  or  by  washing  in  1  :  1000  bichloride 
of  mercury. 

The  incision  should  be  clean  and  smooth,  and  large 
enough  to  give  plenty  of  room  and  permit  easy  recogni- 
tion of  all  the  parts  as  they  are  reached.  If  the  operator 
attempts  to  work  through  too  small  an  opening  his  manip- 
ulations and  efforts  at  retraction  and  clamping  are  liable 
to  cause  bruising  of  the  margins  of  the  wound.     In  order 


30  THE  ACCESSORIES  OF  AN  OPERATION. 

to  minimize  the  amount  of  foreign  material  the  ligatures 
should  be  as  few  and  small  as  possible.  Much  of  the 
hemorrhage  can  be  stopped  by  simple  pressure,  as  by 
clamps  left  in  place  for  a  few  moments,  or  by  temporary 
packing  with  sponges  or  pads  of  gauze.  Strong  antiseptics 
and  rough  handling  in  a  perfectly  clean  wound  are  to  be 
avoided.  After  all  bleeding  has  been  checked,  every  por- 
tion of  the  wound  surface  should  be  brought  into  contact 
with  some  other,  and  held  there  immovably  for  from  five 
to  ten  days.  A  well-applied  dressing,  aided  by  a  few 
sutures,  will  generally  be  found  sufficient  for  this  purpose. 
Buried  sutures  should  be  used  with  caution.  They  un- 
favorably modify  the  nutrition  of  the  parts,  and  thereby 
conduce  to  the  development  of  such  septic  germs  as  may 
be  present. 

The  question  of  drainage  depends  upon  a  number  of 
considerations.  A  large  effusion  of  blood  or  serum  may 
be  expected  to  follow  some  operations,  and,  by  separating 
the  apposed  surfaces  of  the  wound,  prevent  primary  union. 
A  well-applied  dressing  and  sutures  sufficiently  far  apart 
— half  an  inch  to  an  inch — to  allow  the  effusion  to  escape 
between  them  will  generally  suffice.  This  may  be  supple- 
mented by  a  Hat  strip  of  sterilized  rubber  tissue  intro- 
duced into  the  depths  of  the  wound  and  brought  out 
between  the  sutures. 

If  it  is  thought  necessary  to  use  a  drainage  tube  in  an 
aseptic  wound  the  tube  should  be  removed  with  every 
antiseptic  precaution  at  the  end  of  twenty-four  to  thirty- 
six  hours.  Pre-existing  suppuration  in  the  wound  or  its 
vicinity  always  calls  for  drainage.  If  suppuration  occurs 
in  a  previously  aseptic  wound,  every  facility  must  be 
given  for  the  escape  <>f  pus  at  the  earliest  moment.  The 
whole  wound  may  Deed  to  be  laid  wide  open  and  lightly 
packed  with  gauze. 

An  aseptic  wound  is  closed  by  any  suitable  one  of  the 
different  kind-  of  suture  and  covered  with  a  ~iri|»  of  ster- 
ilized rubber  tissue,  over  which  is  placed  a  layer  of  iodo- 
form gauze,  or  the  rubber  tissue  may  be  omitted.  Apply 
next  to  the  iodoform  gauze  compresses  of  sterilized  ab- 


WOUND   MADE  AND   ITS   THE  ATM  EXT.  31 

sorbent  gauze,  cover  these  with  sterilized  absorbent  cot- 
ton, which  acts  as  a  filter  against  germs  coming  from 
without  and  also  absorbs  leakage  from  the  wound. 
Bandage  tightly  enough  to  cause  an  even  pressure  and 
immobilization,  and  yet  not  interfere  with  circulation. 


PART  IT. 


LIGATURE   OF   THE   ARTERIES. 


GENERAL  DIRECTIONS. 


A  point  for  the  application  of  the  ligature  should  be 
chosen,  if  possible,  not  nearer  than  half  an  inch  to  any 
named  branch  above  or  below  it.     The  operator  should 


Fig.  11. 


This  diagram  represents  throe  distinct  operations.     A.  Opening  the  sheath.     B. 

Drawing  ligature  round  the  artery.     ('.  Tying  artery. 

make  himself  thoroughly  familiar  with  the  anatomical  re- 
lations of  the  parts  and  the  landmarks  of  the  operation  ; 
he  should   proceed   methodically,    in   accordance  with   a 


34 


LIGATURE   OF   THE  ARTERIES. 


definite  plan,  and  seek  for  and  recognize  each  layer, 
each  landmark  in  its  order. 

The  incision  should  be  free,  and,  so  far  as  possible,  its 
center  should  correspond  with  the  point  at  which  the 
ligature  is  to  be  applied.  It  should  go  fairly  through 
the  skin  and  be  carried  down  to,  and  then  through,  the 
enveloping  fascia  by  repeated  applications  of  the  knife. 

The  knife  may  then  be  laid  aside  and  the  artery  sought 
for  by  separating  the  tissues  with  the  fingers  or  a  direc- 
tor. The  sheath  is  recognized  by  the  communicated  pul- 
sation and  by  the  absence  of  the  pinkish-white  color  and 
smooth  shining  surface  which  characterize  the  artery. 
When  found,  it  is  pinched  up  with  the  forceps,  the  flat 
of  the  knife  laid  upon  it  and  a  hole  one-quarter  of  an 
inch  lonjr  carefully  made  in  it.  A  distinct  sheath  is 
found  only  about  the  main  trunks  and  is  replaced  in  the 
others  by  a  layer  of  cellular  tissue,  which  is  more  readily 
separated  by  tearing  with  the  point  of  a  director  or  with 
two  forceps. 

When  the  pinkish-white  coat  of  the  vessel  has  been 
fairly  exposed,  each  edge  of  the  hole  in  the  sheath  is 
grasped  in  turn  with  forceps  and  the  sides  of  the  vessel 
gently  separated  from  the  sheath  by  tearing  through  the 
slight  attachments  with  the  point  of  a  director. 

Fig.  12. 


A  1 1  •  1 1  n-  n ill' 


A  threaded  aneurism  needle  is  then  entered  on  that 
side  where  the  parts  li<-  thai  are  most  to  be  avoided  ami 
passed  behind  the  artery,  care  being  taken  not  to  raise 

the    hitter    from    its    lied,   until    it-   eye    appears   upon    the 
other  Bide ;    the  thread   is  then   picked   up  with   forceps 

and  drawn  through  while  the  needle   is  withdrawn.      The 

precaution  should  never  be  omitted  of  trying  if  compres- 
sion of  the  vessel  between  the  finger  and  the  ligature  ar- 


ANATOMY  OF  THE  SUPRA-CLAVICVLAR  REGION.  35 

rests  pulsation  in  its  distal  branches,  for  the  best  sur- 
geons have  mistaken  a  nerve  or  strip  of  fascia  for  the 
artery.  The  main  trunks  can  be  readily  distinguished 
from  the  veins  by  their  appearance — the  veins  being  blu- 
ish, while  the  arteries  are  white  and  feel  like  a  cord  or 
band  under  the  finger — and  by  their  known  anatomical 
relations  ;  but  it  is  often  very  difficult  to  recognize  the 
smaller  arteries,  since  they  closely  resemble  the  veins. 
The  operator  has  to  depend  upon  three  indications  :  (1) 
the  fact  that  when  there  are  two  satellite  veins  the  artery 
is  placed  between  them;  (2)  pulsation;  (3)  alternate 
compression  of  the  vascular  bundle  at  the  two  ends  of 
the  incision.  Pressure  at  the  proximal  end  causes  the 
artery  to  shrink  and  the  veins  to  swell ;  pressure  at  the 
distal  end  has  the  contrary  effect. 

The  ligature  is  then  tied  with  a  square  knot  (Fig.  4), 
tightly  enough  to  cut  the  inner  coats  of  the  vessel,  both 
ends  cut  short  and  the  wound  closed. 


ANATOMY  OF  THE  SUPRA-CLAVICULAR  REGION. 

The  superficial  fascia  underlies  the  platysma,  and  in- 
closes the  sterno-cleido-raastoid  in  a  reduplication  of  itself. 
The  middle,  or  sterno-clavicular,  fascia  has  a  common 
origin  with  the  superficial  fascia  in  the  linea  alba  between 
the  two  sterno-thyroid  muscles,  divides  into  three  layers 
to  form  sheaths  for  the  sterno-thyroid  and  sterno-hvoid, 
unites  and  again  divides  to  form  a  sheath  for  the  omo- 
hyoid, unites  again  and  finally  joins  the  superficial  fascia 
between  the  trapezius  and  sterno-cleido-mastoid.  This 
middle  fascia  is  strong  and  resisting,  and  incloses  all  the 
vessels  of  the  region  except  the  external  jugular  vein, 
which  is  subcutaneous  throughout  its  course  until  it  turns 
inward  to  join  the  subclavian  above  the  clavicle.  These 
two  fascia'  are  separated  from  each  other  and  from  the 
skin  by  loose  cellular  tissue,  in  which  a  large  amount  of 
fat  may  be  deposited,  and  it  is  of  prime  importance  that 
tiny  should  be  recognized  in  the  search  for  the  vessels. 

Tin,'  vessels  which  are  approached   through  this   region 


36 


LIGATURE   OF  THE  ARTERIES. 


are  the  innominate,  the  subclavian,  and  the  common  ca- 
rotid. The  bifurcation  of  the  innominate  corresponds  with 
the  sterno-clavicular  articulation,  and  in  old  people,  as 
well  as  in  exceptional  cases,  rises  from  five  to  ten  milli- 
meters above  it.  It  lies  in  front  and  on  the  right  side  of 
the  trachea,  and  is  crossed  anteriorly  by  the  left  innomi- 
nate vein.  At  the  bifurcation  the  subclavian  lies  behind 
and  to  the  outer  side  of  the  carotid,  and  is  crossed  by  the 
pneumogastrie  and   phrenic  nerves  close  to  its  origin,  the 

Fig.  13. 


</,  «.  Inner  coal  of  an  artery  ruptured  by  a  ligature, 

former  giving  off  the  recurrent  laryngeal,  which  turns 
under  the  artery  and  rises  again  behind  it.  The  carotid, 
which  at  first  lies  behind  the  sterno-cleido-mastoid,  soon 
reaches  it-  anterior  edge,  and  at  the  same  time  increases  its 

distance  from  the  trachea.  While  the  internal  jugular  lies 
wholly  within    the  middle   cervical    fascia,  the   subclavian 

vein  i-  enveloped  by  a  reduplication  of  it  and  held  closely 
againsl  the  clavicle  thereby.  It  is  therefore  more  super- 
ficial, and  on  ;i  lower  plane  than  the  curved  portion  of  the 
subclavian  artery,  and  need  not  be  uncovered  in  the  seai-(d) 
for  the  latter.     The  branches  of  the  subclavian,  seven  in 


LIGATURE  OF  THE  INNOMINATE  ARTERY. 


37 


number,  arise  (with  one  exception,  the  transversalis  colli) 
from  its  first  portion,  that  comprised  between  its  origin 
and  the  inner  border  of  the  scalenus  anticus.  The  trans- 
versalis colli  may  arise  from  the  first  part,  or  the  second 
(between  the  scaleni),  or  even  the  third  (beyond  the  sca- 
leni).  The  supra-scapular  crosses  in  front  of  the  scalenus 
anticus  and  runs  downward  and  outward  to  the  clavicle, 
lying  below  the  line  of  the  incision  made  in  tying  the 
subclavian  in  its  third  portion. 

LIGATURE  OF   THE  INNOMINATE  ARTERY. 

Anatomy. — The  artery  is  in  relation   in  front  with  the 
innominate  veins  and  the  pneumogastric  nerve  ;  on  the 

Fig.  14. 


Ligature  of  Arteries.    A.  Ennouiinate.    B.  Second  or  third  portion  of  subclavian. 

C.  Second  or  third  portion  of  subclavian  (Skey).  D.  Vertebral  or  inferior  thyroid. 
E.  Axillary  below  the  clavicle. 

inner  side  with  the  trachea  ;  on  the  outer  side  and  behind 
with  the  pleura.  It  lies  immediately  behind  the  sterno- 
clavicular articulation. 

Operation. — (Mott.)  An  incision  3|  inches  in  length  is 
carried  along  the  anterior  edge  of  the  right  sterno-cleido- 
mastoid,  ending  half  an  inch  above  the  sternum  (Fig.  14, 
A).  Another,  of  the  same  length,  is  carried  outward 
from  the  lower  end  of  the  first,  half  an  inch  above  and 


38  LIGATURE    OF  THE  ARTERIES, 

parallel  to  the  right  clavicle.  These  incisions  are  carried 
down  to  the  superficial  fascia,  and  the  triangular  flap  be- 
tween them  dissected  up.  If  the  anterior  jugular  is  en- 
countered it  must  be  drawn  downward.  The  sternal  and 
part  of  the  clavicular  attachments  of  the  sterno-cleido- 
mastoid  are  now  divided  half  an  inch  above  the  bone  on 
a  director  or  with  forceps  and  knife,  and  the  muscle 
drawn  upward  and  outward,  uncovering  the  sterno-thy- 
roid  and  sterno-hyoid  and  the  middle  cervical  fascia, 
which  here  is  very  dense  and  covered  by  the  inferior 
thyroid  veins.  The  outer  libers  of  the  sterno-hyoid  and 
sterno-thyroid  are  now  divided,  the  thyroid  veins  drawn 
aside,  and  the  underlying  or  middle  fascia  torn  through 
with  the  director,  or  opened  very  carefully  with  the  knife. 
The  common  carotid  is  now  seen  at  the  bottom  of  the 
wound  and  traced  downward  to  the  innominate.  The 
internal  jugular  is  carefully  pressed  outward  with  a  re- 
tractor ;  the  left  forefinger,  passed  into  the  wound  between 
the  artery  and  the  innominate  veins,  presses  the  latter 
against  the  sternum,  and  the  operator  proceeds  carefully 
to  clean  the  artery  with  a  director  half  an  inch  below  its 
bifurcation.  The  needle,  guided  by  the  finger,  is  passed 
from  the  outer  side  so  as  to  avoid  the  vein,  nerve  and 
pleura. 

Bardenheuer'  exposes  the  innominate  by  resection  of*  a 
portion  of  the  sternum.  A  transverse  incision  is  made 
along  the  upper  border  of  the  sternum  and  inner  third  of 
the  clavicle  on  both  sides.  Another  incision  is  made  in 
the  median  line  at  right  angles  to  this  from  the  larynx, 
well  down  upon  the  sternum.  In  the  transverse  incision 
the  sterno-inastoid,  sterno-hyoid,  and  sterno-thyroid  mus- 
cles, and  the  deep  fascia  are  cut  through.  The  inner  inch 
of  the  left  clavicle  and  firs f  rib  arc  resected  subperiosteally. 
By  working  inward  through  this  gap  the  periosteum  is 
treed  from  the  posterior  surface  of  the  manubrium,  and  this 
bone  is  chiseled  through  transversely  an  inch  below  its 
upper  bonier,  :iikI  removed  by  cutting  the  right  clavicle 
and  firsl  and  second  righl  ribs  close  to  the  sternal  border. 
1  I '-ut.  med.  Woch.,  Vol.  II.,  N<>.  10,  p.  (188. 


LIGATURE  OF   THE  SUBCLAVIAN  ARTERY.        30 

The  periosteum  is  cut  in  the  median  line,  the  left  innom- 
inate vein  is  pushed  down  and  the  right  drawn  to  the  right 
side,  and  the  aneurism  needle  passed  from  right  to  left  to 
avoid  the  pleura. 

The  innominate  has  been  tied  only  for  aneurism  of  itself, 
of  the  subclavian,  or  of  the  primitive  carotid;  but  as  the 
treatment  of  aneurism  by  distal  ligature  yields  satisfactory 
results,  this  operation  is  seldom  justifiable. 

LIGATURE  OF   THE  SUBCLAVIAN  ARTERY. 

The  anatomical  difference  between  the  right  and  left 
subclavian  is  confined  to  the  first  portion  of  the  artery, 
which  in  the  left  is  much  longer,  more  vertical  in  its 
direction,  and  situated  more  posteriorly  even  than  the  in- 
nominate; a  separate  description  therefore  is  required  only 
for  the  first  portion. 

Operation. — 1st  Portion.  Left  Subclavian. — A 
V-shaped  incision  similar  to  that  described  for  ligature 
of  the  innominata  (Fig.  14)  is  made  upon  the  left  side 
and  carried  through  the  sterno-cleido-mastoid  and  outer 
fibers  of  the  sterno-thyroid  and  sterno-hyoid  muscles  and 
the  middle  cervical  fascia  as  before  described.  The 
carotid  is  then  recognized  and,  together  with  the  internal 
jugular,  drawn  outward  with  a  blunt  hook.  The  mus- 
cles are  now  relaxed  by  bending  the  head  and  neck  for- 
ward and  the  cellular  tissue  torn  through  with  forceps 
and  director.  The  knife  should  no  longer  be  used,  on 
account  of  the  risk  of  injury  to  the  thoracic  duct,  which 
is  imbedded  in  the  loose  tissue  between  the  vessels  and 
the  vertebrae  and  is  rendered  very  difficult  of  recognition 
by  its  small  size  and  thin  walls.  It  runs  directly  across 
the  route  to  the  artery  while  passing  from  the  bodies  of 
the  vertebrae  to  the  anterior  border  of  the  scalenus  anti- 
cus  and  can  best  be  avoided  by  making  the  search  below 
and  to  the  outer  side  of  it  in  the  lower  angle  of  the 
wound. 

The  finger,  passed  downward  and  backward  behind 
the  carotid,  soon  feels  the  artery  by  pressing  it  against 


40  LIGATURE  OF  THE  ARTERIES. 

the  side  of  the  spinal  column,  the  loose  cellular  tissue 
surrounding  it  is  easily  separated  with  the  director,  the 
vessel  cleaned  and  the  needle  passed  from  the  inner  side. 
The  needle  should  have  a  short  curve  and  its  point 
should  be  kept  close  against  the  vessel,  so  as  to  avoid  in- 
juring the  pleura. 

1st  Portion.  Right  Subclavian. — It  is  exposed 
in  the  same  manner  as  the  innominate  artery,  and  the 
ligature  passed  from  the  outer  side,  the  pneumogastric 
and  phrenic  nerves  being  pressed  inward  toward  the 
carotid.  The  great  danger  of  this  operation  lies  in  the 
proximity  of  collateral  branches. 

2i>  Portion. — This  operation,  first  proposed  and  per- 
formed by  Dupuytren,  is  rendered  dangerous  by  the  fact 
that  one  and  sometimes  several  large  branches  are  given 
off  from  this  part  of  the  artery.  The  preliminary  steps 
are  the  same  as  those  employed  in  ligature  of  the  3d  por- 
tion ;  after  the  middle  cervical  fascia  has  been  divided, 
the  tubercle  of  the  first  rib  and  the  external  border  of 
the  scalenus  anticus  are  sought,  the  muscles  bared  and 
divided  upon  a  director,  the  phrenic  nerve  which  lies 
upon  its  anterior  aspect  being  carefully  avoided.  As 
soon  as  the  muscular  fiber-  are  cut  they  retract  and  leave 
the  artery  in  full  view. 

.;ii  Portion.  Anatomy. — The  3d  portion  of  the  sub- 
clavian lies  between  the  outer  border  of  the  scalenus  an- 
ticus and  the  tubercle  of  the  first  rib  in  front  and  the 
brachial  plexus  behind,  and  below  the  posterior  belly  of 
the  omohyoid  ;  it  i-  crossed  on  a  much  more  superficial 
plane  by  the  external  jugular,  which  enters  the  subclavian 
Dear  the  middle  of  the  clavicle.  In  muscular  subjects  the 
clavicular  insertions  of  the  trapezius  and  sterno-cleido- 
mastoid  muscles  lie  near  to.  or  may  even  join,  one 
another;  in  others  they  arc  from  two  to  three  inches 
apart.      Ordinarily    the    vessel    lie-   at    a    depth   of  one  or 

one  and  a-half  inches  below  the  surface,  bnt  in  very  fat 
persons,  or  when  the  clavicle  has  been  pushed  upward  by 
an  axillary  aneurism,  this  distance  may  be  increased  t<< 
three  inches. 


LIGATURE  OF  SUPERIOR  THYROID  ARTERY.     41 

Operation. — Beginning  an  inch  outside  of  the  sterno- 
clavicular articulation,  make  an  incision  three  or  four 
inches  long  parallel  to  and  half  an  inch  above  the 
clavicle  (Fig.  14,  B).  Divide  the  skin  and  the  platysma; 
when  the  external  jugular  is  exposed  draw  it  aside  or 
divide  it  between  two  ligatures.  Divide  the  superficial 
fascia,  and  the  clavicular  portion  of  the  mastoid  muscle 
if  necessary,  and  seek  the  posterior  belly  of  the  omohyoid. 
Draw  this  muscle  outward  and  upward,  and  feel  for  the 
tubercle  of  the  first  rib,  following  down  the  outer  border 
of  the  scalenus  anticus.  Depress  the  shoulder  as  much  as 
possible,  denude  the  artery  with  the  point  of  a  director, 
and  pass  the  needle  from  below,  taking  care  not  to  in- 
clude the  lowest  bundle  of  the  brachial  plexus  in  the  liga- 
ture. In  order  to  avoid  mistaking  this  bundle  for  the 
artery,  the  tubercle  of  the  first  rib  should  always  be 
found;  the  artery  lies  against  it,  between  it  and  the  nerve. 

Skey  prefers,  in  difficult  cases,  a  curved  incision  "  com- 
menced about  two  and  a-half  or  three  inches  above  the 
clavicle,  upon,  or  immediately  on  the  outer  edge  of,  the 
mastoid  muscle.  This  incision  is  carried  slightly  out- 
ward and  downward,  toward  the  acromion,  and  then 
curved  inward  along  the  clavicular  origin  of  the  mastoid 
muscle."  (Fig.  14,  C.)  Ordinarily  the  external  jugular 
is  left  to  the  outer  side  of  the  incision. 


LIGATURE  OF  THE  SUPERIOR  THYROID  ARTERY. 

It  arises  close  to  the  bifurcation  of  the  common  carotid 
at  the  upper  border  of  the  thyroid  cartilage,  and  is  in  rela- 
tion with  the  superior  laryngeal  nerve  on  its  inner  side. 

Operation. — A  two-inch  incision  is  made  along  the  ante- 
rior border  of  the  sterno-mastoid  muscle,  with  its  center 
opposite  the  upper  border  of  the  thyroid  cartilage.  The 
skin,  fascia,  and  platysma  are  divided,  the  sterno-mastoid 
drawn  out,  and  the  carotids  recognized. 

The  superior  thyroid  artery  will  be  found  springing 
from  the  anterior  surface  of  the  external  carotid  close  to 
the  bifurcation  of  the  common  carotid  arterv.     Pass  the 


42  LIGATURE  OF  THE  ARTERIES. 

needle  from  above  down,  avoiding  the  superior  laryngeal 

nerve. 

LIGATURE  OF   THE  INFERIOR  THYROID. 

Anatomy. — After  passing  vertically  upward,  the  artery 
curves  inward  to  reach  the  under  surface  of  the  thyroid 
gland.  The  highest  point  of  its  curve  is  half  an  inch 
below  the  prominence  on  the  transverse  process  of  the  sixth 
cervical  vertebra,  named  by  Chassaignac  the  carotid  tuber- 
cle. In  old  people  it  is  somewhat  higher.  It  lies  behind 
the  common  carotid  and  internal  jugular,  and  is  separated 
from  them  by  more  or  less  dense  cellular  tissue.  The 
guides  to  the  vessel  are  the  carotid  and  Chassaignac's 
tubercle. 

Operation. — Make  an  incision  three  and  a-half  or  four 
inches  in  length  along  the  anterior  border  of  the  sterno- 
cleido-mastoid,  ending  an  inch  above  the  clavicle  (Fig.  14, 
1>).  Lay  bare  the  border  of  the  muscle,  and  draw  it  out- 
ward, tear  through  or  divide  the  middle  fascia,  and  draw 
the  carotid  and  internal  jugular  outward,  with  a  retractor. 
Flex  the  head  slightly  to  relax  the  parts,  feel  with  the 
finger  for  the  carotid  tubercle,  and  seek  the  artery  below 
it,  separating  the  cellular  tissue  with  a  director.  Pass  the 
needle  between  the  artery  and  vein. 

Drobeck1  makes  an  incision  along  the  outer  border  of 
the  sterno-mastoid  muscle  from  the  clavicle  to  the  thyroid 
cartilage.  The  omohyoid  muscle  and,  just  below  and  par- 
allel to  it,  the  transversalis  colli  artery  cross  the  wound 
transversely  beneath  the  sterno-mastoid,  and  overlie  the 
phrenic  nerve  as  it  passes  vertically  down  on  the  scalenus 
anticus.  At  the  inner  border  of  the  latter  is  the  ascend- 
in-  cervical  artery.  The  sterno-mastoid  and  great  vessels 
are  drawn  toward  the  median  line,  and  either  the  ascend- 
ing cervical  or  transversalis  colli  artery  is  followed  back 

to  the  thyroid  axis.      The  inferior   thyroid  artery  will   be 

found  at  the  inner  side  of  die  ascending  cervical  close  to 

the  inner  border  of  the  scalenus  anticus  just  below  the 

carotid  tubercle.     The  recurrent  laryngeal  nerve  lies  still 

'<  fcntralbl.  far  Chirunrie,  L887.  i>.  592. 


LIGATURE  OF  AXILLARY  ARTERY.  43 

nearer  the  median  line;  the  ligature  should  be  passed  from 
within  outward. 

LIGATURE  OF  THE    VERTEBRAL  ARTERY. 

Anatomy. — The  vertebral  artery  passes  from  the  first 
portion  of  the  subclavian  upward  and  backward  to  the 
transverse  process  of  the  sixth  cervical  vertebra.  It  is  ac- 
companied by  a  vein  which  lies  in  front,  and  is  covered 
by  the  deep  cervical  fascia.  The  guide  to  it  is  the  carotid 
tubercle. 

Operation. — The  incision  is  the  same  as  for  ligature  of 
the  inferior  thyroid  (Fig.  14,  D).  The  anterior  edge  of 
the  sterno-cleido-mastoid  is  exposed  and  drawn  outward. 
The  middle  fascia  is  divided,  and  the  carotid  and  jugular 
drawn  inward.  The  gap  between  the  longus  colli  and  the 
scalenus  anticus  is  then  felt  for  about  half  an  inch  below 
the  carotid  tubercle,  the  deep  fascia  covering  it  torn 
through,  the  muscles  separated,  the  vertebral  vein  pushed 
aside,  and  the  artery  exposed. 

Chassaignac  prefers  an  incision  along  the  posterior  bor- 
der of  the  mastoid  muscle,  and  reaches  the  carotid  tubercle 
by  drawing  the  muscle  and  vessels  inward.  If  the  muscle 
is  very  broad  some  of  its  clavicular  fibers  must  be  divided. 

LIGATURE  OF  THE  AXILLARY  ARTERY. 

Anatomy. — The  axillary  extends  from  the  middle  of 
the  clavicle  to  the  lower  edge  of  the  tendon  of  the  teres 
major.  The  axillary  vein  lies  on  the  inner  side  and  in 
front  of  it  and  the  brachial  nerves  invest  its  lower  por- 
tion closely.  It  can  be  tied  below  the  clavicle  in  the 
clavi-pectoral  triangle  formed  by  the  clavicle,  inner  bor- 
der of  the  pectoralis  minor  and  the  thorax  or  in  the 
axilla.  The  strong  fascia  which  unites  the  coracoid 
process  and  clavicle  and  forms  the  suspensory  ligament 
of  the  axilla,  the  costo-coracoid  fascia,  sends  a  prolonga- 
tion about  the  upper  portion  of  the  axillary  vein  which 
keeps  its  walls  from  sinking  in  ;  the  cephalic  vein  as- 
cending in  the  groove  between  the  deltoid  and  pectoralis 


44  LIGATURE  OF  THE  ARTERIES. 

major  perforates  this  fascia  and  joins  the  axillary  vein  at 
the  inner  border  of  the  tendon  of  the  pectoral  is  minor, 
close  by  the  origin  of  the  acromial  thoracic  artery. 

A.  Ligature  Under  the  Clavicle.  (Fig.  14,  E.) — Make 
an  incision  extending  from  the  summit  of  the  coracoid 
process  four  or  four  and  a-half  inches  along  the  lower 
border  of  the  clavicle.  Divide  successively  the  skin, 
subcutaneous  tissue,  superficial  fascia  and  pectoralis 
major,  and  then  tear  carefully  through  the  costo-coracoid 
fascia,  avoiding  injury  to  the  cephalic  vein  at  the  outer 
part  of  the  wound.  The  pectoralis  minor  is  now  ex- 
posed, and  after  separating  the  cellular  tissue  with  the 
point  of  a  director  the  axillary  vein  is  seen  crossing  from 

Fig.   15. 


B 


I    > 
A 
A.  Ligature  of  the  axillary  artery.    /:.  Ligature  of  the  brachial  artery. 


the  upper  edge  of  the  muscle  to  the  clavicle.  The  artery 
is  completely  hidden  by  it,  lying  on  the  outer  side  and 
a  little  behind.  The  vein  must  now  be  drawn  inward, 
the  needle  entered  between  it  and  the  artery  and  the 
ligature  applied  as  near  as  possible  to  the  clavicle  on  ac- 
eniuit  of  the  proximity  <>f  the  acromial  thoracic  branch. 
B.  Ligature  in  the  Axilla.  Anatomy. — The  (issues  and 
organs  on  the  outer  side  of  the  axilla  are  arranged  in  the 
following  order :  (1)  the  skin;  ('2)  the  subcutaneous  cel- 
lular tissue;  (3)  the  fascia;  (1)  the  axillary  vein;  (5) 
the  internal  cutaneous  and  ulnar  nerves  ;   (li)   the  axillary 

artery;  i7)  the  median  nerve;  (8)  the  coraco-brachialis ; 

(9)  the  humerus  and  articular  capsule.      'Flic  old   rule   for 
exposing   the  artery  here  was   to   make  a  longitudinal  in- 


LIGATURE  OF  BRACHIAL  ARTERY.  45 

cision  at  the  junction  of  the  anterior  and  middle  thirds  of 
the  axilla,  find  the  vein,  count  two  nerves  and  look  for 
the  artery  just  beyond  the  last  one.  This  is  a  difficult 
and  dangerous  method  and  a  much  simpler  one  has  been 
substituted  by  Malgaigne,  who  was  the  first  to  point  out  that 
the  coraco-braehialis  muscle  is  the  real  guide  to  the  artery. 
Operation. — The  arm  is  abducted  completely,  the  in- 
cision commenced  at  the  inner  border  of  the  coraco- 
braehialis  over  the  head  of  the  humerus  and  carried  two 
and  a-half  or  three  inches  down  the  arm  parallel  to  the 
course  of  the  artery.  It  should  involve  the  skin  only,  so 
as  to  avoid  injury  to  the  basilic  vein.  If  the  edge  of  the 
coraco-braehialis  cannot  be  distinguished,  the  incision 
should  be  made  according  to  the  old  rule,  at  the  junc- 
tion of  the  anterior  and  middle  thirds  of  the  axilla. 
The  aponeurosis  is  now  divided  upon  a  director  over  the 
coraco-braehialis,  and  the  fibers  of  the  inner  border  of  this 
muscle  exposed.  The  parts  are  then  relaxed  by  bringing 
the  arm  nearer  the  trunk,  and  the  posterior  side  of  the 
wound,  including  the  vein,  ulnar  and  internal  cutaneous 
nerves,  is  drawn  back  with  a  retractor  ;  and  the  artery, 
overlain  by  the  median  nerve,  usually  appears  at  the  bot- 
tom, covered,  perhaps,  by  the  posterior  part  of  the  sheath 
of  the  coraco-braehialis. 

LIGATURE  OF  THE  BRACHIAL  ARTERY. 
Anatomy. — The  brachial  artery  runs  from  the  junction 
of  the  anterior  and  middle  thirds  of  the  axilla  to  the  mid- 
dle of  the  anterior  aspect  of  the  elbow.  It  occupies,  when 
the  forearm  is  supinated,  the  groove  between  the  biceps 
and  triceps,  being  partly  covered  by  the  former  in  mus- 
cular subjects,  and  separated  from  the  bone  by  the  inner 
edge  of  the  coraco-braehialis,  and  of  the  brachialis  an- 
ticus.  It  lies  in  the  anterior  loge  of  the  arm,  which  is 
bounded  posteriorly  on  this  side  by  a  prolongation  of  the 
enveloping  aponeurosis,  extending  down  to  the  bone  be- 
tween the  biceps  in  front  and  the  triceps  behind.  It  lies, 
consequently,  within  the  sheath  of  the  biceps,  and  the 
inner  edy;e  of  this  muscle  is  the  sure  2-uide  to  it.      It  lies 


46 


LIGATURE   OF   THE  ARTERIES. 


between  two  satellite  veins,  which  anastomose  frequently, 
and  has  the  median  nerve  in  immediate  relation  with  it 
on  the  side  next  the  skin.  The  basilic  vein  directly 
overlies  it  between  the  skin  and  the  aponeurosis.  The 
artery  presents  frequent  anomalies.     The  most  common  is 


Fig.  16. 


Transverse  section  of  the  arm  at  its  middle  (Tillaux).  i.  Skin.  'J.  Subcuta- 
neous tissue.  '■'•■  Enveloping  aponeurosis,  i.  Aponeurosis  separating  the  anterior 
and  posterior  loges  on  trie  inner  side.  5.  Division  on  the  outer  side.  6.  Brachial 
artery  and  veins.  7.  Median  nerve.  8.  Basilic  vein.  9.  Internal  cutaneous  nerve. 
10.  ulnar  nerve.  II.  Its  artery  and  veins.  12,  Muscular  cutaneous  nerve,  i::. 
Muscular  spinal  nerve.     14.  Superior  profunda  artery.     i">.  Cephalic  vein. 

it>  premature  bifurcation  into  the  radial  and  ulnar,  which 
may  take  place  as  high  as  in  the  axilla,  in  which  case  one 
of  the  branches  is  superficial,  perhaps  even  subcutaneous, 
while  the  other  follows  the  usual  course.  The  median 
nerve  occupies  the  same  sheath  with  the  artery,  lying  first 


LIGATURE  OF  RADIAL  ARTERY.  47 

on  the  outer  side  and  then  crossing,  in  front  or  behind,  very 
obliquely  to  the  inner.  The  ulnar  nerve,  accompanied  by 
an  artery  and  two  veins,  lies  in  the  substance  of  the  triceps 
immediately  behind  the  brachial  artery  and  median  nerve, 
separated  from  them  only  by  the  above  mentioned  prolon- 
gation of  the  enveloping  aponeurosis,  and  as  they  form  a 
group  differing  from  the  other  only  in  size,  the  artery  may 
be  mistaken  for  the  brachial  if  met  with  (Fig.  16).  This 
error  will  not  be  made  if  the  fibers'of  the  biceps  alone  are 
exposed  and  the  incision  confined  to  the  anterior  loge. 

Operation. — Arm  abducted,  forearm  snpinated.     Make 
an  incision  three  inches  long  in  the  middle  third  of  the 

Fig.  17. 


Ligature  of  the  brachial  artery. 

arm,  along  the  inner  border  of  the  biceps  through  the  skin 
and  subcutaneous  cellular  tissue,  taking  care  not  to  injure 
the  basilic  vein,  which  should  be  kept  posterior  to  the 
incision.  Divide  the  aponeurosis  and  expose  the  fibers  of 
the  biceps.  If  the  muscle  is  large  draw  it  forward,  and 
the  sheath  inclosing  the  artery,  nerve,  and  veins  will  be 
disclosed.  This  is  opened  carefully,  the  median  nerve 
separated  and  pushed  aside,  the  artery  separated  from  its 
veins,  and  the  ligature  passed  from  the  side  of  the  nerve. 

LIGATURE    OF    THE    RADIAL    ARTERY. 

Anatomy. — The  radial  artery  extends  in  a  straight  line 
from  a  point  half  an  inch  below  the  center  of  the  fold  of 


48 


LIGATURE  OF  THE  ARTERIES. 


the  elbow  to  the  ulnar  side  of  the  styloid  process  of  the 
radius  ;  it  occupies  the  groove  bounded  on  one  side  by  the 
supinator  longus,  on  the  other  by  the  pronator  radii  teres 
and  flexor  carpi  radialis.  It  is  covered  only  by  the  skin, 
cellular  tissue,  and  aponeurosis  ;  but  in  muscular  subjects 
the  muscular  interstice  in  which  it  lies  may  be  very  deep. 
It  is  accompanied  by  two  veins  and  by  no  nerve.  It  oc- 
cupies in  its  upper  third  the  sheath  of 
the  pronator,  and  consequently  the  fibers 
of  the  supinator  longus  should  not  be 
exposed  in  the  search  for  the  artery, 
although  the  edge  of  the  muscle  may 
be  taken  as  a  guide  to  it.  The  radial 
nerve  lies  within  the  sheath  of  the  su- 
pinator longus,  and  at  first  comes  quite 
close  to  the  artery  ;  it  then  passes  behind 
and  to  the  outer  side  of  the  tendon  of  the 
muscle.  It  should  not  be  seen  during 
the  operation. 

Operation.  In  the  Upper  Third. — 
Make  an  incision  two  and  one-half  inches 
long  in  the  line  above  mentioned,  begin- 
ning one  and  one-half  inches  below  the 
fold  of  the  elbow.  Avoiding  the  super- 
ficial veins,  carry  the  incision  to  the 
fascia.  Recognize  the  edge  of  the  supi- 
nator longus,  and  divide  the  fascia  along 
the  ulnar  side  of  it,  exposing  the  fibers 
of  the  pronator.  Tress  apart  the  two 
muscles  if  necessary,  separate  the  artery 

fr it>  veins,  and  pass  the  ligature. 

In   THE    LOWER   THIRD  (Fig.  18). —  Make  an  incision 
in  the  above-mentioned  line,  if  the  position  of  the  artery 

cannot  be  made  out  by  its  pulsations,  two  inches  long, 
ending  an  inch  above  the  wrist.  Divide  the  fascia  in 
the  9ame  line,  separate  the  artery  from  the  two  veins  and 

pass  the  ligature. 


Ligature  <<f  the  radla 
aad  ulnar  arteries. 


LIGATURE  OF  THE   ULNAE   ARTERY.  49 

LIGATURE  OF   THE  ULNAR  ARTERY. 

Anatomy. — In  its  first  third  the  ulnar  artery  passes 
obliquely  underneath  the  superficial  layer  of  muscles,  in- 
cluding  the  superficial  flexor  of  the  fingers,  to  the  inner 
side  of  the  arm,  where  it  becomes  superficial  and  lies  be- 
tween the  flexor  carpi  ulnar  is  on  the  inside  and  the  flexor 
sublimis  digitorum  on  the  outside.  It  then  descends  to 
the  wrist  in  the  direction  of  a  line  uniting  the  internal 
condyle  of  the  humerus  with  the  outer  border  of  the  pisi- 
form bone.  It  is  accompanied  by  two  veins  and  is  joined 
by  the  ulnar  nerve  just  before  it  becomes  superficial,  the 
nerve  lying  upon  the  inner  or  ulnar  side  of  the  artery. 
It  may  be  tied  at  any  point  in  the  middle  and  lower 
thirds.  As  the  deep  and  superficial  flexors  of  the  fingers 
are  separated  by  a  fascia,  and  as  the  artery  lies  below  this 
fascia,  it  is  covered  in  the  lower  part  of  its  course  by  two 
distinct  fascia1,  the  enveloping  fascia  of  the  limb  and  this 
second  one. 

Operation.  At  the  Junction  of  the  Uppee  and 
Middle  Thirds. — Beginning  four  finger-breadths  below 
the  internal  condyle  of  the  humerus  make  an  incision 
three  and  one-half  or  four  inches  long  in  the  line  above 
mentioned  (Fig.  18).  Expose  the  enveloping  fascia 
clearly,  and,  drawing  back  the  posterior  lip  of  the 
wound,  seek  the  first  muscular  interstice  in  front  of  the 
ulna.  It  is  that  between  the  flexor  carpi  ulnaris  and  the 
flexor  sublimis  digitorum,  and  can  be  recognized  by  the 
finger  as  a  slight  depression,  or  by  the  eye  as  a  white 
line  under  the  fascia.  Divide  the  fascia,  beginning  at 
the  lower  angle  where  the  space  between  the  muscles  is 
broadest,  and  then,  instead  of  following  the  interstice  di- 
rectly backward,  raise  the  flexor  sublimis  and  advance 
transversely  across  the  arm  in  the  search  for  the  artery 
which  lies  upon  the  dee})  flexor.  Isolate  the  artery  and 
pass  the  needle  from  the  side  of  the  nerve. 

Ix  the  Lower  Third  (Fig.  18). — Make  an  incision 
slightly  to  the  radial  side  of  the  tendon  of  the  flexor  carpi 
ulnaris,  or  in  the  line  before  mentioned,  two  inches  long, 
and  ending  an  inch  above  the  end  of  the   ulmi.     Divide 


50  LIGATURE   OF  THE  ARTERIES. 

the  enveloping  fascia  upon  a  director,  and  tear  through  the 
second  over  the  vessel,  which  can  be  seen  and  felt  through 
it.  Isolate  the  artery,  and  pass  the  needle  from  within 
outward  so  as  to  avoid  the  nerve. 

LIGATURE  OF  THE  COMMON  CAROTID. 

The  place  of  election  for  ligature  of  the  common  carotid 
is  just  above  the  omohyoid  muscle,  but  the  lesion  which 
renders  the  ligature  necessary  may  require  it  to  be  applied 
at  a  much  lower  point.  The  vessel  has  been  tied  success- 
fully at  a  point  one-eighth  of  an  inch  from  its  origin  at  the 
bifurcation  of  the  innominata. 

The  steps  necessary  to  place  a  ligature  upon  the  common 
carotid  in  the  first  part  of  its  course  are  the  same  as  for 
ligature  of  the  first  portion  of  the  subclavian  or  of  the 
innominata  (7.  v.).  After  the  vessel  has  been  exposed, 
the  internal  jugular  is  pressed  to  the  other  side,  the  artery 
denuded,  and  the  needle  passed  from  the  side  of  the  vein. 

At  thp]  Place  of  Election. — The  bifurcation  of  the 
common  carotid  is  on  a  line  with  the  upper  border  of  the 
thyroid  cartilage.  The  place  of  election  for  tying  it  is 
about  three-quarters  of  an  inch  below  its  bifurcation.  The 
guide  to  the  artery  is  the  anterior  border  of  the  sterno- 
eleido-mastoid  muscle,  and  the  danger  is  of  wounding  the 
jugular  vein,  which,  when  lull,  entirely  covers  the  artery 
on  the  outer  side. 

Operation. — Make  along  the  anterior  border  of  the  ster- 
no-cleido-niastoid  an  incision  three  inches  in  length,  the 
•  ■enter  of  which  corresponds  with  the  crico-thyroid  space 
(  Fig.  1 !»).       I  >ivide  the  skin,  platysma,  cellular  tissue,  and 

aponeurosis,  mid  seek  tor  the  interstice  between  the  sterno- 
cleido-mastoid  and  the  sub-hyoid  muscles.  When  found, 
the  hitter  must  be  pressed  inward,  and  the  artery  will 
appear  ;it  the  edge  of  the  sterno-cleido-mastoid,  the  vein, 
which  i-  external  to  it,  remaining  covered.     The  ueedleis 

passed  from  without   inward. 

If,  instead  of  pressing  the  trachea  and  its  muscles  in- 
ward, the  ?terno-mastoid  i^  drawn  outward,  the  vein  is 
encountered,  almosl  completely  overlying  the  artery. 


LIGATURE  OF   THE  EXTERNAL   CAROTID. 


51 


LIGATURE   OF    THE    EXTERNAL    CAROTID. 

The  free  anastomoses  which  exist  within  the  cranium 
between  the  two  internal  carotids  render  ligature  of  the 
common  carotid  insufficient  certainly  to  arrest  hemorrhage 
from  the  external  carotid  ;  the  ligature  must  be  applied  to 
the  vessel  itself,  despite  the  number  of  its  branches  and 
the  difficulty  of  recognizing  them  at  the  bottom  of  the 
incision.     The  operation  is  a  difficult  one,  for  there  are 


Fig.  19. 


DiuioD  carotid  at  t lie  place  of  election. 


many  important  organs  to   be   avoided,  and  there   is   no 
direct  guide  to  the  vessel. 

Anatomy. — The  common  carotid  divides  opposite  the 
upper  border  of  the  thyroid  cartilage  (a  little  lower  in 
females)  into  the  external  and  internal  carotids,  which 
occupy  nearly  the  same  an tero- posterior  plane,  the  former 
being  in  front.  At  about  three-quarters  of  an  inch  above 
the  bifurcation  the  arteries  cross,  the  external  becoming 
posterior,  the  internal  anterior.  The  internal  carotid 
gives  off  no  branches  outside  the  cranium,  while  the 
external  gives  off  eight.  Of  these  the  superior  thyroid 
arises  at  or  very  near  the  bifurcation,  the  lingual,  facial, 
ascending  pharyngeal,  and  occipital  near  the  point  where 


52  LIGATURE   OF   THE  ARTERIES. 

the  artery  passes  under  the  digastric,  about  an  inch  above 
the  bifurcation,  the  others  at  a  considerable  distance 
above.  The  hypoglossal  nerve  looping  around  the  occip- 
ital artery  at  its  origin  crosses  the  external  carotid  send- 
ing a  branch,  the  descendens  noni,  down  the  outside  of  the 
artery. 

There  are  thus  three  means  of  distinguishing  the  ex- 
ternal carotid :  (1)  its  branches ;  (2)  its  position  with 
reference  to  the  internal  carotid  ;  (3)  its  immediate  rela- 
tions with  the  hypoglossal  nerve,  the  internal  carotid  oc- 
cupying a  deeper  plane.  In  a  search  for  the  external 
carotid  the  operator  may  be  satisfied  with  either  of  these 
guides,  accordingly  as  one  or  the  other  presents  itself. 
Should  the  nerve  be  first  encountered,  he  will  tie  the 
vessel  upon  which  it  lies  ;  should  both  vessels  lie  at  the 
bottom  of  the  incision,  he  will  know  that  the  anterior 
one  is  the  external  carotid  ;  and  if  the  vessel  which  he 
isolates  has  a  branch,  he  knows  it  cannot  be  the  internal 
carotid. 

Although  the  risks  arising  from  the  proximity  of  a 
ligature  to  a  large  branch  are  greatly  reduced  by  asepsis, 
vet  it  is  still  desirable  that  a  certain  interval  should  be 
maintained  ;  and  from  this  point  of  view  the  first  half- 
inch  of  the  artery  and  the  portion  underlying  the  digas- 
tric are  the  places  of  election,  and  of  these  two  the  former 
alone  is  practicable.  The  connective  tissue  surrounding 
the  two  arteries  at  their  origin  is,  however,  unusually 
compact,  rendering  their  denudation  so  difficult  that  any 
search  lor  branches  would  be  dangerous  to  the  nutrition 
of. the  vessel's  wall. 

M.  (iiiyon1  has  .-how  n  that,  while  the  lingual  and 
superior  thyroid  arteries    vary   greatly    in    their   points   of 

origin,  the  average  distance  between  them  is  from  12  to  IN 
millimeters,  or  over  half  an  inch ;  he  calls  the  portion  of 
the  vessel  between  them  the  "  trunk  of  the  external  caro- 
tid," and  suggests  thai   the  ligature  should  be  applied  (! 

nun.     below    the    point    at     which    the   hypoglossal    nerve 

crosses  the  artery,  this  nerve  being,  in  the   greal  majority 

1  M6moircs  de  la  ><■<•.  <|<  <  birurgie,  1864,  p.  655. 


LIGATURE  OF  Till:  INTERNAL   CAROTID. 


63 


of  cases,  in  immediate  relation  with  the  origin  of  the  lin- 
gual artery. 

Operation. — When  the  head  is  extended  and  the  face 
turned  to  the  opposite  side,  an  incision  carried  from  the 
angle  of  the  jaw  to  the  anterior  border  of  the  sterno- 
cleido-mastoid  opposite  the  top  of  the  thyroid  cartilage 
will  cross  the  artery  obliquely  (Fig.  20,  B).  It  must  be 
carried  through  the  skin,  platysma,  and  subcutaneous  cel- 
lular tissue,  the  external  jugular  being  drawn  aside  when 


Fig.  20. 


Ligature  of — A.  Lingual  art< 


/>'.  External  carotid.     C  Occipital.     1>.  Temporal. 
A'.   Facial. 


encountered.  The  fascia  is  then  divided  in  the  line  of 
the  incision,  care  being  taken  not  to  deviate  to  the  right 
or  left,  and  when  the  artery  has  been  thus  exposed  and 
cleaned,  the  needle  is  passed  from  behind  forward. 

The  lymphatic  glands  of  the  region  are  numerous  and 
often  large,  and  may  be  mistaken  for  the  artery.  There 
is  no  objection  to  removing  any  that  may  interfere  with 
the  search  for  the  vessel. 


LIGATURE    OF    THE    INTERNAL    CAROTID. 

This  is  to  be  done  according  to  the  method  described 
for  the  external  carotid. 


•r>4  LIGATURE  OP  THE  ARTERIES. 

LIGATURE    OF    THE    LINGUAL    ARTERY. 

Anatomy. — The  lingual  artery  arises  from  the  external 
eamtid,  on  a  level  with  the  great  horn  of  the  hyoid  bone, 
and  passes  between  the  middle  constrictor  of  the  pharynx 
and  the  hyoglossus  upward  and  forward.  It  is  occasion- 
ally accompanied  by  a  small  vein,  but  the  lingual  vein  is 
separated  from  it  by  the  thickness  of  the  hyoglossus  mus- 
cle. Its  one  important  branch,  the  sublingual,  sometimes 
has  its  origin  at  or  near  the  point  where  the  lingual  is 
usually  tied,  and  may  be  mistaken  for  it.  The  artery 
may  be  tied  near  its  origin,  between  the  great  horn  of  the 
hvoid  bone  and  the  posterior  belly  of  the  digastric,  but 
its  depth  at  this  point,  and  the  presence  of  large  veins. 
make  the  operation  difficult  and  dangerous.  The  place  of 
election  is  in  the  triangle  bounded  posteriorly  by  the  pos- 
terior belly  <>f  the  digastric,  anteriorly  by  the  posterior 
border  of  the  mylo-hyoid,  and  above  by  the  hypoglossal 
nerve.  It  is  covered  at  this  point  by  the  skin,  platysma, 
cervical  aponeurosis,  submaxillary  gland,  and  the  hyo- 
glossus  muscle,  the  libers  of  which  form  the  Moor  of  the 
triangle  just  described. 

Operation. — Make  a  curved  incision  two  inches  long,  its 
concavity  directed  upward,  its  center  one-quarter  of  an  inch 
above  the  hvoid  bone  at  a  point  midway  between  the  median 
line  and  the  extremity  of  the  great  horn  |  Fig.  20,  .1 1.  Di- 
vide the  skin  and  platysma  and  then  the  cervical  aponeu- 
rosis, which  may  be  very  thin.  Raise  the  submaxillary 
gland,  find  the  posterior  belly  of  the  digastric,  it-  attach- 
ment to  the  hyoid  bone,  the  posterior  border  of  the  mylo- 
hyoid, and   the  hypoglossal    nerve  ac< panied   by   the 

1+ug^ial  vein.  Draw  the  hyoid  bone  slightly  downward 
with  a  blunt  hook  fixed  in  the  lower  angle  of  the  triangle 
bounded  by  these  organs,  and  then,  pinching  up  the  fibers 
of  the  hyoglossus  with  a  pair  of  forceps,  divide  them  care- 
fully along  a  line  parallel  to  the  nerve,  mid  midway  between 

it  and  the  bone.  A-  the  cul  liber-  retract,  the  artery  i- 
disclosed  beneath  them  •,  separate  it  from  its  vein,  it'  there 
be  one,  and  pass  the  ligature. 


LIGATURE   OF  THE  FACIAL   ARTERY. 


;>;> 


LIGATURE  OF  THE  FACIAL  ARTERY. 
The  facial  artery  crosses  the  inferior  maxilla  just  in 
front  of  the  anterior  edge  of  the  niasseter,  from  which  it 
is  separated  by  the  facial  vein  (Fig.  21).  The  artery  can 
he  exposed  by  a  vertical  incision  along  its  course,  or  by  a 
horizontal  one  along  the  lower  border  of  the  maxilla. 


Fig.  21. 

PAROTID  aiA,No 


Occipital  a._ 


Facial  a. 

Mylohyoid  n. 

Submental  a. 


Hypoglossal  n 

Descendcns  noni  n 
Lingual  a 


Internal  jugular  v. 
Superior  thyroid  a 


Common  carotid 


Anatomies]  relations  of  the  lingual  and  facial  arteries. 

Operation.  (Fig.  20,  E.) — Beginning  at  the  lower 
edge  of  the  maxilla,  make  an  incision  one  inch  in  length 
along  the  course  of  the  artery  ;  divide  the  skin,  subcu- 
taneous tissue  and  fascia  ;  separate  the  artery  from  the 
vein  and  pass  the  needle  between  them. 

If  the  horizontal  incision  is  used,  it  should  extend 
three-quarters  of  an  inch  on  each  side  of  the  artery,  the 
anterior  edge  of  the  masseter  should  be  recognized  and 
the  vessel  sought  for  immediately  in  front  of  it. 


56  LIGATURE  OF  THE  ARTERIES. 

LIGATURE  OF   THE  OCCIPITAL  ARTERY. 

At  the  Mastoid  Process. — The  guides  to  the  vessel 
are  the  apex  and  posterior  border  of  the  mastoid  process, 
the  digastric  groove  on  its  inner  surface  and  the  digastric 
muscle. 

Operation.  (Fig.  20,  (7.) — Starting  from  a  point  half 
an  inch  below  and  in  front  of  the  apex  of  the  mastoid 
process,  carry  the  incision  two  inches  obliquely  backward 
parallel  to  the  border  of  this  process.  Divide  the  skin 
and  enveloping  fascia,  and  then  the  sterno-mastoid  and  its 
insertion  throughout  the  entire  length  of  the  incision. 
Then  divide  the  splenius  and  its  shining  aponeurosis  and 
feel  for  the  digastric  groove.  Pinch  up  and  carefully  di- 
vide a  thin  fascia  which  covers  the  anterior  face  of  the 
splenius.  Starting  from  the  belly  of  the  digastric,  sepa- 
rate  the  cellular  tissue  in  the  anterior  angle  of  the  wound 
with  a  director,  denude  the  artery  and   tie.      (ChauvelJ) 

LIGATURE  OF  THE  TEMPORAL  ARTERY. 

(Fig.  20,  D.)  Make  a  transverse  incision  one  inch 
long,  extending  from  the  tragus  of  the  car  forward  over  the 
zygomatic  arch.  Separate  the  subcutaneous  cellular  tis- 
sue, which  i>  very  dense  and  fibrous,  with  a  director,  and 
seek  the  artery  imbedded  in  it  about  a  quarter  of  ;m  inch 
in  front  of  the  ear.  Press  the  vein  backward,  pass  the 
needle  from  behind  forward,  taking  care  not  to  include  in 
the  ligature  the  temporal  branch  of  the  auriculo-temporal 
nerve,  which  i-  sometimes  in  close  relations  with  the  artery. 

LIGATURE  OF  THE  ABDOMINAL  AORTA. 
This  operation  has  been  performed  about  a  dozen  time-, 
with  :i  liitiil  resull  iii  every  case.  The  patients  survived 
for  periods  varying  from  ;i  few  hour-  to  ten  days.  The 
artery  may  be  reached  through  the  abdominal  cavity  by 
an  incision  in  the  median  line,  or,  without  dividing  the 
peritoneum,  by  an  incision  in  the  flunk  similar  to  Ki'mig's 
for  extirpation  of  the  kidney  ('/.  r.).  The  application  of 
:i   ligature,  even  under  the  most   favorable  circumstances, 


LIGATURE  OF  THE  COMMON  ILIAC  •>< 

alter  the  artery  has  been  exposed  by  the  latter  method, 
requires  the  utmost  dexterity,  the  chance  of  exciting  peri- 
tonitis is  great,  and  the  presence  of  the  aneurism  and  the 
displacements  and  adhesions  it  has  caused  may  render  it 
impossible  to  reach  the  vessel. 

Operation.  THROUGH  THE  PERITONEAL  CAVITY. — 
An  incision  in  the  linea  alba,  from  a  point  three  inches 
above  the  umbilicus  to  one  three  inches  below  it  ;  press 
the  intestines  aside  with  flat  sponges,  carefully  incise  the 
peritoneum  covering  the  aorta,  separate  the  nerves  from  its 
anterior  surface,  and  pass  the  ligature  from  the  outer  side. 

LIGATURE  OF  THE  COMMON  ILIAC. 

Anatomy  of  the  Common,  Internal,  and  External  Iliac 
Arteries. — The  aorta  bifurcates  usually  on  the  left  side  of 
the  fourth  lumbar  vertebra,  and  the  direction  of  the  com- 
mon and  external  iliacs  is  i"epresented  by  a  line  drawn  from 
a  point  an  inch  above  the  umbilicus  to  another  one-half  an 
inch  external  to  the  center  of  Poupart's  ligament.  The 
common  iliac  is  usually  two  inches  long,  and  bifurcates  at 
thesacro-iliac  synchondrosis,  but  this  bifurcation  may  take 
place  at  any  point  between  one  and  a-lialf  and  three  or 
even  four  inches  from  the  origin  of  the  artery.  The  com- 
mon iliac  gives  off  no  branches. 

The  external  iliac  runs  downward  and  outward  along  the 
brim  of  the  pelvis  from  the  bifurcation  to  a  point  under 
Poupart's  ligament  midway  between  the  anterior  superior 
spine  of  the  ilium  and  the  symphysis  pubis.  Its  two 
branches,  the  epigastric  and  circumflex  ilii,  are  given  oft* 
nearly  opposite  each  other,  a  short  distance  above  Pou- 
part's ligament,  sometimes  much  higher. 

The  internal  iliac  runs  downward  and  backward  into 
the  pelvis  for  one  and  a-half  inches,  dividing  at  the  upper 
border  of  the  great  sacro-sciatic  foramen  into  two  large 
trunks.  The  ureter  crosses  the  vessels  at  or  just  below 
the  bifurcation  of  the  common  iliac,  the  vas  deferens  two 
and  a-half  or  three  inches  lower.  Both  are  more  closely 
adherent  to  the  peritoneum  than  to  the  arteries.  The  iliac 
veins  lie  upon  the  inner  side  and  posterior  to  the  arteries  ; 


58 


LIGATURE   OF  THE  ARTERIES. 


both  pass  behind  the  right  common  iliac,  the  right  vein  at 
its  bifurcation,  the  left  vein  much  higher  up.  The  sper- 
matic vessels  and  genito-crural  nerve  lie  in  front  of  the 
external  iliac  at  the  lower  part  of  its  course,  and  the  cir- 
cumflex iliac  vein  crosses  it  at  the  same  place. 

The  abdominal  wall  at  the  points  where  the  incisions 
are  made  is  composed  of  the  following  layers  in  the  order 
named:  skin,  subcutaneous  cellular  tissue,  fascia,  external 
oblique  or  its  aponeurosis,  internal  oblique,  transversalis, 
and  transversalis  fascia. 

Extra-peritoneal  Operation. — Beginning  at  a  point  a 
finger's  breadth  above  Poupart's  ligament  and  just  outside 


Fig.  22. 


Ligature  of    A.  Coi on  Iliac.     B.  External  iliac,    C.  Femoral  in  Scarpa's  space. 

of  the  external  iliac  artery,  make  an  incision  four,  five, 
or  six  inches  in  length,  according  to  the  thickness  of  the 
abdominal  wall,  parallel  at  first  to  Poupart's  ligament,  and 
curving  upward  after  passing  the  anterior  superior  spine  of 
the  ilium  (  Fig.  22).  J  divide  the  skin,  subcutaneous  tissue, 
and  fascia,  exposing  the  aponeurosis  of  the  external  oblique, 
divide  the  latter  throughout  the  whole  extent  of  the  in- 
cision,  and  then  divide  the  fibers  of  the  internal  oblique 
and  transversalis  by  pinching  them  up  with  the  forceps 
and  cutting  carefully  with  repeated  touches  of  the  knife, 
until  the  fascia  transversalis,  which  varies  much  in  density. 


LIGATURE  OF  nil'  ixri:i:\M.  iliac  59 

is  exposed.  Raise  the  fascia  at  the  lower  angle  of  the 
wound,  where  it  is  most  dense,  with  forceps,  and  make  a 
hole  in  it  largo  enough  to  admit  the  finger.  Pass  the  fore- 
finger through  this  hole,  press  back  the  peritoneum  with 
it,  and  enlarge  the  hole  upward  in  the  line  and  to  the  full 
extent  of  the  incision,  the  finger  being  kept  between  the 
peritoneum  and  the  knife. 

The  peritoneum  is  now  raised  from  the  psoas  and 
rliacus  muscles  and  drawn  upward  and  inward  by  an  as- 
sistant, while  the  operator  seeks  for  the  external  iliac  and 
passes  the  forefinger  of  his  left  hand  along  it  to  the  com- 
mon iliac,  the  thighs  being  flexed  t<>  relax  the  abdominal 
wall-.  As  it  is  seldom  that  a  good  view  of  the  artery 
can  be  obtained,  the  finger  must  be  kept  upon  it  and  the 
loose  cellular  tissue  in  which  it  is  imbedded  very  gently 
separated  with  the  point  of  a  director.  When  the  artery 
has  been  properly  cleaned,  pass  the  needle  from  within 
outward. 

Intra-peritoneal  Operation. — Open  the  abdomen  in  the 
median  line  by  an  incision  extending  from  the  symphysis 
pubis  to  or  a  little  above  the  umbilicus  and,  after  pushing- 
aside  the  intestines  with  flat  sponge-  or  pads,  aided  by 
the  Trendelenburg  position,  cut  through  the  peritoneum 
overlying  the  artery  and  pass  the  ligature  from  within 
outward. 

('are  must  be  taken  not  to  include  the  ureter,  which 
usually  crosses  the  vessel  at  its  point  of  bifurcation.  In 
the  extra-peritoneal  operation  there  is  less  danger  of  this 
accident,  as  the  ureter  is  adherent  to  the  peritoneum  and 
is  lifted  out  of  the  way  a-  this  membrane  is  stripped  up. 

LIGATURE  OF  THE  INTERNAL  ILIAC. 

Its  accompanying  vein  lies  behind  and  on  the  inner  side. 

Extra-peritoneal  Operation. — Same  as  for  ligature  of  the 
common  iliac.  After  the  peritoneum  has  been  lifted  up, 
the  finger  i-  passed  along  the  external  iliac  to  the  bifur- 
cation and  then  downward  for  half  an  inch  along  the 
internal  iliac.  The  vein  being  carefully  protected,  the 
artery  is  bared  and  the  ligature  passed  from  within  outward. 


60  LIGATURE  OF  THE  ARTERIES. 

The  intra-peritoneal  operation  does  not  differ  enough 
from  that  for  tying  the  common  iliac  to  require  a  sepa- 
rate description. 

Ligature  of  the  internal  iliac  has  been  seldom  employed 
except  for  traumatic  gluteal  aneurism,  and  in  these  eases, 
as  Van  Buren1  pointed  out,  the  treatment  should  be  to 
cut  down  upon  the  sac,  and  tie  both  ends  of  the  artery, 
hemorrhage  being  controlled  by  digital  pressure  made 
upon  the  internal  iliac  from  within  the  rectum. 

LIGATURE  OF  THE  EXTERNAL  ILIAC. 

Various  cutaneous  incisions  have  been  recommended  for 
this  operation.  Sir  Astley  Cooper's  extended  from  the 
external  abdominal  ring  to  within  a  short  distance  of  the 
superior  spine  of  the  ilium  ;  the  objections  to  it  arc  that  it 
involves  the  division  of  the  superficial  epigastric,  and,  per- 
haps, of  the  internal  epigastric  also,  and  that  the  ligature 
can  be  applied  only  to  the  lower  part  of  the  artery. 
Abernethy's  extended  outward  from  the  internal  inguinal 
ring  parallel  to  Poupart's  ligament ;  by  it  the  vessel  is 
reached  at  a  greater  depth,  but  it  has  the  great  advan- 
tage of  allowing  extension,  so  that  if  it  should  prove 
necessary  the  ligature  may  be  applied  even  to  the  com- 
mon iliac.  By  curving  the  outer  portion  of  the  incision 
upward  away  from  the  superior  spine  of  the  ilium,  the 
main  branches  of  the  circumflex  ilii  may  be  avoided. 

Operation. —  Beginning  over  the  outer  side  of  the  artery 
:i  finger's  breadth  above  Poupart's  ligament,  make  an  in- 
cision three  or  four  inches  in  length,  at  first  parallel  with 
Poupart's  ligament,  and  then  curving  upward  (Fig.  22). 

Carry  this  incision  through  the  abdominal  wall,  and  raise 

the  peritoneum  from  the  surface  of  the  iliacus  and  psoas 
muscles  in  the  same  manner  as  lor  ligature  of  the  common 

iliac.       Flex  the  thighs  so  as  to  relax  the  abdominal  iniis- 

cles,  and,  while  mi  assistant  draws  the  peritoneum  and 
tin    contained    intestines   upward    and   inward,  seek   the 

artery  upon  the  inner  border  of  the  psoas,      (lean  it  with 

'Report  on  "Aneurism,"  Proceedings  of  the  International  Medical 
(  ongresB,  1876. 


LIGATURE  OF  INTERNAL  PUDIC  ARTERIES. 


61 


a  director  or  pair  of  forceps,  and  pass  the  needle  from 
within  outward. 

For  the  intra-peritoneal  operation  an  incision  along  the 
lower  part  of  the  linea  semilunaris  would  generally  be 

better  than  one  in  the  median  line,  and  possibly  McBnr- 
ney's  inter-muscular  method  of  reaching  the  appendix 
(7.  r.)  would  give  sufficient  room. 

LIGATURE   OF   THE   GLUTEAL,  SCIATIC,  AND  INTER- 
NAL PUDIC  ARTERIES. 

The  proper  treatment  of  injury  to  either  of  these  arteries 
is  to  enlarge  the  wound  and  tie  both  ends  of  the  divided 
vessel,  but  it  may  happen  that  this  would  be  impossible, 


Fig.  23. 


Ligature  of— J.  Gluteal  artery.    />'.  Sciatic  and  internal  pudic. 

and  that  ligature  in  continuity  is  required.  The  necessary 
incisions  are  those  shown  in  Fig.  2-*>.  The  place  at  which 
the  gluteal  artery  emerges  from  the  great  sciatic  notch 
may  be  roughly  stated  as  opposite  a  point  at  the  junction 
of  the  upper  and  middle  thirds  of  a  line  joining  the  pos- 
terior superior  spine  of  the  ilium  with  the  great  trochanter. 


62  LIGATURE  OF  THE  ARTERIES. 

The  sciatic,  where  it  crosses  the  spine  of  the  ischium, 
lies  opposite  the  junction  of  the  middle  and  lower  thirds 
of  a  line  joining  the  tuberosity  with  the  posterior  superior 
spine  of  the  ilium. 

After  division  of  the  skin  and  faseia,  the  fibers  of  the 
gluteus  maximus  are  separated  and  held  apart  with  long 
retractors,  the  deep  fascia  torn  through,  and  the  artery 
sought  for. 

The  gluteal  artery  is  to  be  sought  for  above  the  pyri- 
formis  muscle  at  the  upper  border  of  the  great  sacro-sciatic 
notch,  where  it  can  be  felt  near  a  small  bony  tubercle.  It 
is  covered  by  many  large  veins,  which  require  very  care- 
ful handling.  The  ligature  should  be  applied  as  close  to 
the  notch  as  possible. 

The  sciatic  and  internal  j)ii<Jic  arteries  leave  the  great 
sciatic  notch  at  the  lower  edge  of  the  pyrifbrmis;  the 
former  divides  almost  immediately,  the  latter  reenters  the 
pelvis  through  the  lesser  sacro-sciatic  notch,  lying  on  the 
inner  side  of  the  sciatic  artery  during  its  passage  over  the 
spine  of  the  ischium. 

LIGATURE  OF  THE  FEMORAL  ARTERY. 
Anatomy. — The  femoral  artery  is  the  continuation  of  the 
externa]  iliac,  and  extends  in  a  straight  line  from  a  point 
midway  between  the  anterior  superior  spine  of  the  ilium 
ami  the  symphysis  pubis  to  the  ring  in  the  tendon  of  the 
adductor  magnus  about  lour  finger-breadths  above  the 
tubercle  of  insertion  of  that  muscle  on  the  upper  portion 
of  i  he  inner  condyle  of  the  femur.  In  the  first  one  or  two 
inches  of  its  course  it  gives  off  the  superficial  external 
pudic,  epigastric,  and  circumflex  ilii,  and  the  much  larger 

and  more  important  profunda  arteries.  The  anastoinotica 
magna  arises  near  it.~  lower  cud.  The  artery  is  accom- 
panied throughout  l>v  the  femoral  vein,  which,  at  first,  lies 
u|>"ii  the  inner  side,  and  then  becomes  posterior.  They 
ii  separated  at  first  by  a  distinct  septum,  which  disap- 
pears in  the  lower  third.  The  anterior  crural  nerve 
emerges  from  below  Poupart'a  ligament,  about  half  an  inch 
external  to  the  artery  ;  it  divides  up  rapidly,  and  one  of 


LIGATURE  OF  THE  FEMORAL  ARTERY.  63 

its  branches,  the  internal  or  long  saphenous,  enters  the 
sheath  of  the  vessels  three  or  four  inches  below  the  groin, 
and  leaves  it  again  after  the  artery  has  entered  Hunter's 
canal  ;  this  name  being  given  to  the  condensed  sheath  for 
a  short  distance  above  and  below  the  point  where  it  passes 
through  the  tendon  of  the  adductor  inagnus.  The  artery 
passes  under  the  sartorius  at  about  the  junction  of  its 
upper  and  middle  thirds. 

Ligature  of  the  femoral  above  the  origin  of  the  pro- 
funda has  proved  unsatisfactory  and  has  been  generally 
abandoned  for  that  of  the  external  iliac.  The  artery  may 
be  tied  at  any  part  of  its  course,  but  the  point  generally 

Fig.  24. 


Ligature  of  the  femoral  arterj  . 

chosen  is  at  the  apex  of  Scarpa's  triangle,  next  that   in 
the  middle  of  the  thigh  and,  lastly,  in  Hunter's  canal. 

Operation.  A.  At  the  Ai-kx  of  Scarpa's  Tri- 
angle (Figs.  22  and  24). — Make  an  incision  three  or 
four  inches  long,  the  center  of  which  shall  be  a  little- 
above  the  point  where  the  inner  border  of  the  sartorius 
crosses  a  line  drawn  from  the  middle  of  Poupart's  liga- 
ment to  the  inner  tuberosity  of  the  femur.  The  internal 
saphenous  vein  should  be  out  of  danger  on  the  inner  side 
of  the  incision.  Divide  the  skin,  subcutaneous  tissue  and 
the  fascia  lata,  exposing  the  fibers  of  the  sartorius,  which 
may  be  recognized  by  their  direction  downward  and   in- 


64  LIGATURE  OF  THE  ARTERIES. 

ward,  those  of  the  adductors,  on  the  contrary,  being 
downward  and  outward.  The  limb  should  now  be 
slightly  Hexed,  the  vessels  recognized  by  the  touch  at  the 
inner  border  of  the  sartorius,  this  muscle  drawn  outward 
and  the  sheath  of  the  vessels  pinched  up  with  forceps  on 
the  outer  side  (the  vein  lying  on  the  inner)  and  opened. 
The  needle  is  then  passed  from  within  outward. 

B.  In  the  Middle  <>f  the  Thigh. — Here  the  vessel 
lies  underneath  the  sartorius  which  overlaps  it  on  both 
sides.  The  incision  is  made  in  the  line  above  mentioned, 
it-  center  being  a  little  above  the  middle  of  the  thigh; 
the  sartorius  i^-  exposed  and  drawn  outward  after  the  leg 
has  been  further  flexed.  The  vessel  is  then  sought  for, 
exposed  and  tied  as  before. 

( '.  Ix  Hunter's  Canal. — Abduct  and  Hex  the  thigh, 
and  rotate  it  outward  so  as  to  make  the  adductors  tense  ; 
feel  for  the  tendon  of  the  adductor  magnus  and  make  an 
incision  three  or  four  inches  long,  the  center  of  which  is 
at  the  junction  of  the  lower  and  middle  thirds  of  the 
thigh,  in   the  direction  of  the  tendon,  which   is  that  of  a 

line  drawn  from  the  spine  of  the  pubis  to  the  tuberch 

the  inner  condyle  of  the  femur.  Divide  the  skin  and 
subcutaneous  tissue  carefully  so  as  not  to  wound  the  in- 
ternal saphenous  vein,  and  then  the  fascia  upon  a  director. 
Recognize  the  libers  of  the  sartorius  and  of  the  vnstus  in- 
tertill- which  are  at  right  angles  with  one  another,  and  by 
pressing  the  former  inward  or  the  latter  outward  the 
tendon  of  the  adductor  and  the  curved  glistening  fibers 
arching  from  it  to  the  vastus  internus  are  exposed.      If 

the    saphenous    nerve    is    now    encountered    it    should    be 

traced  upward,  a  director  passed   into  the  orifice  through 

which  it  emerges,  and  the  aponeurosis  divided  upward  ;  if 
the  nerve  is  not  seen  it  should  not  be  sought  for,  but  the 
aponeurosis  should  lie  pinched  up  and  divided  close  to  the 
tendon  of  the  adductor.  The  sheath  of  the  vessels  i>  now 
opened,  and  the  artery  is  separated  from  the  closely  ad- 
herent   Vein.        The     needle    should     be     pa-.-cd     from    witllill 

outward. 


LIGATURE  OF  ANTERIOR  TIBIAL  ARTERY.        65 

LIGATURE  OF  THE  POPLITEAL  ARTERY. 

The  artery  lies  very  deep  between  the  condyles  of  the 
femur,  imbedded  in  fat,  and  directly  covered  by  the  vein, 
the  walls  of  which  are  thick  and  stiff  like  those  of  an 
artery.  The  short  saphenous  vein  perforates  the  fascia 
near  the  center  of  the  popliteal  space,  and  empties  into 
the  main  trunk. 

Operation. — Make  an  incision  three  or  four  inches  long 
in  the  vertical  diameter  of  the  popliteal  space,  the  center 
of  which  shall  correspond  to  the  point  at  which  the  liga- 
ture is  to  placed.  Divide  the  skin  and  cellular  tissue, 
taking  care  not  to  injure  the  saphenous  vein,  and  then  the 
fascia  to  the  full  extent  of  the  cutaneous  incision.  Flex 
the  leg-,  have  the  sides  of  the  wound  drawn  widely  apart, 
ami  work  down  through  the  fat  and  lymphatic  glands  to 
the  artery,  leaving  first  the  nerve  and  then  the  vein  upon 
the  outer  side.  Protecting  the  vein  with  one  finger,  de- 
nude the  artery  and  pass  the  needle  from  without  inward. 

If  for  any  reason  it  is  not  convenient  to  place  the 
patient  face  downward,  the  upper  portion  of  the  artery 
can  be  readily  reached  through  an  incision  on  the  inner 
aspect  of  the  thigh  passing  between  the  tendon  of  the  ad- 
ductor magnus  on  one  side,  and  the  sartorius,  semi-mem- 
branosus,  and  semi-tendinostis  on  the  other.  The  artery 
is  found  lying  close  to  the  femur. 

LIGATURE  OF   THE  ANTERIOR   TIBIAL  ARTERY. 

Anatomy. — After  perforating  the  interosseous  mem- 
brane at  the  upper  part  of  the  leg,  the  anterior  tibial 
runs  in  a  direction  which  is  that  of  a  line  drawn  upon 
the  anterior  aspect  of  the  leg  from  the  upper  tibio-fibular 
articulation  to  a  point  midway  between  the  malleoli.  It 
lies  at  first  between  the  belly  of  the  tibialis  anticus  and 
that  of  the  extensor  communis  digitorum  upon  the  inter- 
osseous membrane,  afterward  between  the  tibialis  anticus 
and  the  extensor  proprius  pollicis  or  their  tendons  upon 
the  tibia.  It  is  accompanied  by  two  veins  and  the  an- 
terior tibial    nerve,  which   latter  lies  first  upon  the  outer 


66  LIGATURE  OF  THE  ARTERIES. 

side  and  then  w*>s*erv4tr-frorit  to  the  mueFsfde.     It  may 
be  tied  at  any  point  in  its  course. 

Operation. — Make  in  the  above-mentioned  line  an  inci- 
sion the  length  of  which  will  vary  according  to  the  depth 


Fig.  25. 


Transverse  section  of  the  leg,  upper  third.     (Tillaux.)     T.  Tibia.     /•'.  Fibula. 
/./■:  Enveloping  fascia     DF.  Deep  fascia  'li\i'liirj  to  Inclose  /'/'.  Posterior  tibial 

artery  and  nerve,  and  PA.  Peroneal  artery.     TA.  Tibialis  anticus  sole.    AT. 

Interior  arterj  and  nerve.     /.'/.    [nteross -  membrane.     P.    Peroneus  longus 

muscle.     TS.  internal  saphenous  vein.     ES.  External  saphenous  vein  and  nerve. 

;it  which  the  artery  is  placed.  Divide  the  skin  and  cellu- 
lar tissue,  lay  bare  the  fascia,  and  divide  it  along  (lie  firsl 
muscular  interstice,  which  shows  as  a  while  line  under 
ii  ;  make  also  ;i  transverse  incision  through  the  fascia 
from  t  he  middle  of  the  longitudinal  one  to  the  crest  of  the 


LIGATURE  OF  THE  POSTERIOR   TIBIAL.  67 

tibia,  so  as  to  give  more  room.  Flex  the  foot  upon  the 
leg,  separate  the  muscles  from  below  upward  with  the 
finger,  draw  them  apart  with  retractors,  isolate  the  artery 
without  raising  it,  and  pass  the  needle  from  the  side  of 
the  nerve. 

LIGATURE   OF  THE   DORSALIS  PEDIS. 

This  artery  is  the  continuation  of  the  anterior  tibial, 
and  passes  through  the  posterior  end  of  the  first  metatarsal 
space  to  the  plantar  aspect  of  the  foot.  It  lies  on  the  j 
outer  side  of  the  tendon  of  the  extensor  proprius  poliieis-, 
and  i^  crossed  in  its  lower  portion  by  the  inner  tendon  of 
the  extensor  brevis.  It  is  covered  by  the  skin,  superficial 
fascia,  the  edge  of  the  extensor  brevis,  or  its  tendon,  and  a 
deep  fascia.  Its  direction  is  that  of  a  line  drawn  from  a 
point  midway  between  the  malleoli  to  the  posterior  end 
of  the  first  metatarsal  space.  The  incision  should  be  in 
this  line,  and  the  tendon  of  the  extensor  proprius  pollici- 
should  be  left  on  the  inner  side. 

LIGATURE  OF  THE  POSTERIOR  TIBIAL. 

The  posterior  tibial  artery  in  its  upper  and  middle  por- 
tions lies  upon  the  tibialis  posticus  and  the  flexor  com- 
munis digitorum,  and  is  covered  by  the  soleus,  from  which 
it  is  separated  by  the  deep  fascia.  Near  the  ankle  it  is 
covered  only  by  the  integument  and  fascia.  In  its  upper 
portion  it  can  be  reached  by  two  routes  :  (1)  the  one  em- 
ployed by  Guthrie,  and  approved  of  by  Spenceand  Holmes, 
through  the  middle  of  the  calf;  (2)  the  one  in  more  com- 
mon use,  from  the  inner  side  of  the  calf. 

Operation  (GUTHRIE). — Beginning  at  the  lower  angle  of 
the  popliteal  space,  make  an  incision  six  inches  in  length 
directly  downward,  avoiding  as  far  as  possible  the  super- 
ficial veins,  cany  this  incision  through  the  soleus,  divide 
the  deep  fascia,  separate  the  artery  from  the  vein  and 
nerve,  which  are  superficial  to  it,  and  pass  the  needle  from 
their  side. 

Lateral  Method. — Beginning  in  the  middle  of  the 
upper  third  of  the  leg,  make  an  incision  downward  from 


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PART   III. 

AMPUTATIONS. 


Amputations  may  be  //<  cnntinuitji  (through  the  bone), 
or  in  contiguity  (through  a  joint) ;  to  the  latter  the  term 
(lixarticulation  is  usually  applied.  The  methods  of  opera  - 
tion  are  classified  as  circular,  oval  and  flap,  and  the  choice 
of  a  method  is  determined  by  the  disposition  of  the  soft 
parts  about  the  bone,  the  facility  with  which  the  joint  can 
be  opened  in  a  disarticulation,  the  form  of  the  resulting 
stump  and  the  position  of  the  cicatrix.  The  comparative 
merits  of  these  methods  and  their  various  modifications 
will  be  discussed  in  connection  with  the  different  opera- 
tions. They  may  be  essentially  modified  by  accidental  cir- 
cumstances and  by  the  necessity  which  sometimes  arises 
of  fashioning  the  flap  from  such  tissues  as  are  available. 

CIRCULAR  METHOD. 

1st  Step. — The  cutaneous  incifdoji  should  be  made  at 
a  distance  below  the  point  where  the  bone  is  to  be  di- 
vided equal  to  two-thirds  of  the  diameter  of  the  limb  at 
that  point.  While  an  assistant  draws  the  skin  firmly  and 
evenly  upward,  the  operator  passes  his  hand  beneath  and 
beyond  the  limb  and  places  the  heel  of  the  knife  upon  its 
upper  surface,  its  point  directed  toward  his  own  shoulder. 
He  then  sweeps  the  knife  entirely  around  the  limb,  divid- 
ing  the  s,kjn  °"^  eiihpnfnnpnijs  cellular  tissue,  down  to 
the  enveloping  fascia  and  terminating  the  incision  at  the 
point  where  it  began. 

2d  Step. — a.  The  skin  and  cellular  tissue  are  retracted 
and  the  muscles  divided  in  succession,  the  deeper  ones  at 

71 


72  AMPUTATIONS. 

higher  levels,  so  that  the  surface  of  section  forms  a  cone, 
the  apex  of  which  is  directed  upward.  The  muscles  win  >se 
origins  are  most  distant  must  be  cut  long  to  allow  for  their 
greater  retraction. 

OH*  b.     fCUTANEPTTK     ftT.T.K.HF.  ^ The      skin      flnd      cellular 

tissue  are  separate*!  cleanly  from  the  deep  fascia  and 
turned  back  over  the  limb,  the  raw  surface  outward.  The 
glpnyp  tliiw_J'o|-nied  is  lengthened  by  drawing  it  up  and  di- 
viding its  attachments  to  the  fascia,  care  being  taken  to 
include  all  the  subcutaneous  cellular  tissue  in  it,  until  the 
dissection  has  nearly  reached  the  height  at  which  the  bone 
is  to  be  divided.  The  fascia  and  muscles  are  then  cut 
through  to  the  bone  transversely  with  a  single  sweep  of 
the  knife,  held  as  for  making  the  cutaneous  incision. 

3d  Step.  Division  of  the  Bone. — The  spft  parts 
being  dvM^yn  up-, and  protected  )w  a  munlin  H"d  four 
inches  wide  and  two  feet  long,  split  for  half  its  length  so 
as  to  pass  on  each  side  of  the  bone  (called  the  retractor), 
and  the  periosteum  having  been  divided  circularly  with 
the  knife  along  or  a  little  below  the  line  to  be  traversed 
by  the  saw,1  the  operator  places  the  heel  of  the  saw  upon 
the  bone,  steadies  its  edge  with  the  thumb-nail  of  his  left 
hand,  and  draws  it  slowly  toward  himself,  cutting  a  deep 
groove  in  the  bone;  he  then  completes  the  division 
with  rapid  strokes  of  the  instrument,  while  the  limb  is 
firmly  held  by  two  assistants  so  as  to  prevent  binding  of 
the  saw  or  splintering  of  the  bone. 

[f  there  are  two  bones  the  retractor  should  be  split  into 

threcJii.-le.nl  of  tun  parts,  and  the  central  one  passed  be- 
tween the  bonis.  The  saw  should  be  first  applied  to  tin- 
lanrcr  boiil',  and,  after  cutting  a  deep  groove  in  it,  should 
be  inclined  backward  or  forward,  so  as  entirely  to  divide 
the  secinul  hofmy  com  plet  ii|o-  the  division  of  the  first. 
Gigli'fi    roughened  wirj',  which    is   so  convenient  a  sub- 

1  The  plan  sometimes  employed  of  shinning  up  a  sleeve  of  lu-ri- 
ostenm  and  dividing  the  bone  al  ii^  hase  is  without  value  in  tl.i 


ami  is  highly  objectionable   in  the  vouiiif,  because   it  is   likely  to  lend  to 
the   production,  within   the  periosteal  sleeve,  of  B  spike  of  hone.      This 

i-  the  common  cause  of     conical   si p."  nol   the  disproportionate 

growth  of  the  bone  al  the  epiphysis,  as  has  been  alleged. 


FLAP  METHOD.  73 

stitute  for  the  chain  saw,  may  be  used  for  the  division  of 
even  the  largest  bones  of  the  limbs,  and  is  sometimes 
more  convenient  than  a  saw  because  of  difficulty  in  keep- 
ing the  soft  parts  out  of  the  way  of  the  latter.  In  using 
the  wire  it  should  be  held  taut  and  in  a  widely-opened 
angle  about  the  bone.  The  slight  charring  of  the  flesh 
as  the  wire  becomes  heated  does  no  harm  ;  it  can  be  pre- 
vented by  pouring  water  upon  the  wire. 

OVAL   METHOD. 

A  scalpel  is  used  instead  of  the  amputating  knife  ;  the 
incision  is  commenced  at  the  level  at  which  the  bone  is  to 
be  divided,  is  carried  downward  on  one  side,  across  the 
back  of  the  limb,  and  upward  on  the  opposite  side  to  the 
point  at  which  it  began.  The  details  will  be  given  in 
connection  with  certain  disarticulations  to  which  this 
method  is  especially  applicable. 

FLAP  METHOD. 

The  flaps  may  be  single  or  double,  antero-posterior,  bi- 
lateral, long  rectangular  (Teale),  or  skin  flaps  with  cir- 
cular division  of  the  muscles  (modified  flap  operation). 
They  may  be  made  by  transfixion  or  from  without  in- 
ward. In  making  a  flap  .by  transfixion  it  is  well  first  to 
mark  its  outline  by  an  incision  through  the  skin  and  cel- 
lular  tissue  with  a  scalpel,  as  otherwise  there  is  danger  of 
making  its  point  too  narrow  or  its  edges  jagged.  The 
point  of  the  amputating  knife  is  then  entered  at  the  near- 
est angle  of  the  incision  and  passed  through  to  the  other, 
hugging  the  bone  on  its  way,  and  the  cut  made  steadily 
downward  to  the  apex,  with  sawing  movements  of  the 
knife.  It  is  then  reentered  and  brought  out  at  the  same 
points,  but  passing  on  the  opposite  side  of  the  bone,  and 
the  second  flap  cut  in  the  same  manner  as  the  first.  The 
fibers  on  each  side  of  the  bone  which  have  escaped  are 
then  divided,  the  retractor  applied,  and  the  bone  sawed 
through  as  above. 

In  cutting-  a  flan  from  without  inward  the  scalpel  must 
be  entered  at  one  of  the  angles  of  the  base  of  the  proposed 


74  AMPUTATIONS. 

flap,  carried  along  a  curved  line  down  to  the  apcxof  the 
flap,  and  thence  up  to  the  other  angle  of  the  base.  The 
presence  of  a  tumor,  or  injury  to,  or  disease  of,  the  soft 
parts  may  render  it  necessary  to  modify  the  shape  of  the 
flap  or  vary  the  obliquity  of  the  incision,  so  as  not  to 
include  any  unfit  tissue  in  the  former. 

Skin  Flaps  and  Circular  Division  of  the  Muscles. — In 
this  operation  the  flaps  include  pply  tln>  ^-in  mul  milu-nfM- 
neons  cellular  tissue  dissected  off  from  the  deep  fascia  ;  the 
latter  and  the  muscles  are  divided  transversely  by  a  sweep 
of  the  knife  at  the  base  of  the  flap,  the  retractor  applied, 
and  the  bone  cleaned  and  divided  a  little  higher  up. 

Long  Anterior  Flap. — An  anterior  fhrp.  its  length  some- 
ulint  oTi'jihT  tli:n-|  the  antero-posterior  diameter  of  the  lhn,l> 
at  its  base,  is  cut  by  transfixion,  or  from  without  inward  ; 
the  posterior  ninscles  and  segment  of  skin  are  cut  straight 
across  a  little  below  the  point  of  division  of  the  hone,  and 
the  anterior  flap  brought  down  to  cover  their  cut  surface. 
This  method  furnishes  a  good  covering  for  the  bone,  and 
a  well-placed  cicatrix. 

In  every  amputation  it  is  well  to  dissect  out  the  mam 
nerve  trunks,  and  cut  them  off  high  up  between  the  mus- 
cles, so  that  their  ends  may  not  become  imbedded  in  the 
cicatrix. 

The  choice  of  one  or  another  method  will  often  be  deter- 
mined by  the  anatomical  and  pathological  circumstance- 
of  the  case.  When  any  one  may  be  used,  the  preference  is 
usually  given  now  to  the  skin  flap  with  circular  division 
of  the  muscles. 

Teale's  Method. —  In  the  method  to  which  Mr.  Teale's 
name  has  been  given  a  very  long  rectangular  anterior  flap. 
comprising  half  the  circumference  of  the  limb  and  all  the 
tissues  down  to  the  boia\i-  made  and  doubled  back  upon 

itself,  thus  furnishing  a  thick  pad  for  the  bone  and  a  pos- 
terior cicatrix.      The  method  of  operating  is  as  follows: 

i  Fig.  II.  /.')  A  rectangular  anterior  Mjip  (posterior  in  the 
forearm),  enmal  in  length  and  bread \U  to  hajf  the,  cirenm- 
ference  of  the  limb  at  the  base  of  the  flap,  is  marked  out 
by  one  transverse  and  two  parallel   longitudinal  incisions, 


AMPUTATION  OF  THE  FlNGtiRS.  75 

the  latter  involving  only  the  skin,  the  former  being  carried 
down  to  the  bone.  The  longitudinal  incisions  should  be 
so  placed  that  the  principal  vessels  and  nerves  will  m^t  he 
included  in  this  flap,  but  in  the  posterior  one,  which  is 
afso  bounded  by  a  transverse  incision  carried"  down  to  the 
bone,  and  is  only  one-fourth  as  long  as  the  anterior  one. 
The  two  flaps  are  now  in  turn  dissected  up  close  to  the 
bone,  and  the  saw  applied  at  their  base.  After  the  vessels 
have  been  secured  the  Ion"1  flap  is  doubled  back  npoji 
itself,  and  its  square  end  fastened  to  that  of  the  other  with 
sutures;  two  or  three  points  of  suture  are  also  required  to 
keep  the  sides  of  the  short  flap  and  of  the  reversed  portion 
of  the  long  flap  in  contact  with  the  rest  of  the  latter. 

It  is  found  that  Jjy  retraction  of  the  short  posterior 
flap  the  cicatrix  is  drawn  up  behind  and  out  of  the  way 
of  the  bone,  and  that  a  soft  mass  without  any  large  ves- 
sels or  nerves  is  the  result  of  the  partial  atrophy  of  the 
long  flap  and  forms  an  excellent,  non-sensitive  stump. 
The  principal  objection  to  this  method,  one  which  greatly 
restricts  its  applicability,  is  the  great  length  of  the  anter- 
ior flap,  which  can  be  obtained  in  many  cases  only  by  di- 
viding the  bone  at  a  much  higher  point  than  would  other- 
wise be  necessary. 

AMPUTATION  OF  THE  FINGERS. 
Phalanges. — When  the  injury  or  disease  is  limited  to 
one  or  two  fingers  and  is  of  such  a  nature  that  the  mem- 
ber will  be  useless,  if  [(reserved,  the  affected  phalanx  or 
finger  should  be  removed  without  hesitation  ;  but  usually 
it  is  desirable  to  save  as  much  as  possible  of  the  parts 
and,  therefore,  whenever  a  choice  can  be  made  amputa- 
tion in  continuity  is  to  be  preferred  to  disarticulation 
higher  up.  The  incisions  should  be  SO  arranged  that  the 
cicatrix  will  not  lie  upon  the  palmar  surface,  and  for  this, 
as  well  as  for  anatomical  reasons,  the  principal  flap  should 
be  taken  from  the  flexor  aspect.  Xo  special  directions 
are  required  for  amputation  or  disarticulation  of  the  mid- 
dle and  distal  phalanges.  For  amputation  through  the 
shaft  the  incision  may  be  circular  with  a  longitudinal  ad- 


76  AMPUTATIONS. 

dition  one-third  of  an  inch  long  on  each  .side,  or  the  sin- 
gle anterior  flap  by  transfixion  may  be  used.  In  disar- 
ticulation it  is  best  to  enter  the  joiyt  from  the  dorsnl  sifje 
with  a  narrow-bladed  knife  and  cut  the  anterior  flap  bv 
carrying  the  knife  through  the  joint  and  then  forward. 
hugging  the  bone. 

It  must  be  remembered  that  the  folds  on  the  palmar 
surface  of  a  finger  do  not  correspond  exactly  to  the  joints  ; 
the  first  being  half  an  inch  hevono1.  the  middle  one  a  line 
above,  and  the  distal  one  a  quarter  of  an  ineh  nhovTf  the 
articular  surfaces,  and  also  that  the  prominence  of  a 
knuckle  when  the  finger  is  flexed  is  formed  entirely  by  the 
head  of  the  proximal  and  not  by  the  base  of  the  distal 
phalanx.  When  the  tissues  have  not  become  thickened  and 
infiltrated  the  articular  depressions  can  be  felt  upon  the 
sides. 

Amputation  Through  the  Metacarpo-phalangeal  Articu- 
lation.— The  articular  depression  can  be  found  very  easily 
bypassing  the  thumb  and  forefinger  along  the  sides  of  the 
finger,  especially  if  the  latter  be  at  the  same  time  drawn 
forcibly  away  from  its  metacarpal  bone. 

The  incision  should  be  commenced  over  the  dorsum  of 
the  metacarpal  boin?  a^juarter  of  an  inch  above  the  artic- 
ulation, carried  through  the  interdigital  wcj>,  and  then 
back  on  the  palmar  faqe.  {o  a  point  a  quarter  of  an  incji 
above  the  flexor  fold  (  Fig.  28,  C)\  a  similar  incision,  be- 
ginning and  ending  at  the  same  points,  is  made  on  the 
other  side  of  the  finger,  the  flaps  dissected  back,  the  lat- 
eral ligament-  divide]  while  the  finger  is  drawn  firsl  to 
one  side  and  then  to  the  other  so  as  to  facilitate  access  to 
them  and  at  the  same  time  make  them  tense,  and  then  the 
tendon-  and  the  remainder  of  the  capsule  divided  as  the 
finger  ifi  withdrawn. 

(Jx  an  incision  may  be  made  only  on  the  side  corre- 
sponding to  the  right  hand  of  the  operator,  the  flap  dis- 
Bected  back  to  the  joint,  the  lateral  Ligament  divided;  the 
knife, carried  transversely  through  the  joint,  dividing  the 
tendonsand  the  other  lateral  ligament,  and  the  other  fla.p. 
cut  from  within  outwmxl,  care  being  taken  to  make  it  Bllf- 
ficiently  broad. 


AMPUTATION  OF  THE  METACARPAL   BONES.      77 

The  head  of  the  metacarpal  bone  should  he  removed 
only  in  eases  where  it  is  more  desirable  to  diminish  the 
deformity  than  to  preserve  the  strength  of  the  hand. 

The  incisions  may  be  advantageously  modified  for  the 
index  and  little  fingers  by  making  a  full  lateral  flapjm 
the  free  side  and  carrying  the  incision  transversely  across 

Fig.  28. 


A.  Disarticulation  of  the  phalanx,  anterior  flap.  />'.  Amputation  in  continuity, 
circular.  C!  Metacarpophalangeal  disarticulation.  /'.  Amputation  of  a  metacar- 
pal hone  in  continuity.  E.  Disarticulation  of  little  finger.  F.  Disarticulation  of 
fifth  metatarsal.      G.   Amputation  of  wrist,  circular.      /A   Amputation  of  wrist. 

(DUBBUEIL.  ) 

the  palmar  surface  to  the  angle  of  the  web,  and  thence 
obliquely  back  to  the  knuckle  (Fig.  28,  E). 


AMPUTATION   OF   THE  METACARPAL  BONES. 
As  the  articulations  of  the  first  and  fifth  metacarpal 
bones  with  the  carpus  do  not  communicate  with  the  other 
and  larger  synovial  sacs,  these  bones  may  be  entirely  re- 


7^  AMPUTATIONS. 

moved  without  much  danger  of  setting  up  inflammation 
within  the  wrist-joint,  but  in  the  case  of  the  other  throe 
amputation  in  continuity  is  preferable  to  disarticulation 
ill  unclean  ca-cs.  The  relations  of  the  synovial  sheaths 
t>S  the  flexor  tcndoijs  are  also  of  importance  in  the  opera- 
tion. There  is  op  communication  between  the  main  sin  ath 
in  the  palm  of  the  han^l  and  the  sheaths  of  the  index, 
middlcj  and  ring J fingers,  and  consequently,  if  those  ten- 
dons are  divided  as  low  down  as  the  metacarpophalangeal 
articulation,  inflammation  of  the  main  sheath  with  all  its 
disastrous  consequences  will  probably  be  avoided. 

The  incisions  are  the  same  as  for  amputation  through 
the  metacarpophalangeal  articulation,  with  a  prolongation 
upward  as  far  as  may  be  necessary  oyer  the  back  of  tnn 
bpjia,(Fig.  28,  D).  After  its  posterior  and  lateral  sur- 
faces have  been  bared,  the  bjuie  is  cut  through  with  pliers 
at  the  point  determined  on  (or  i-  disarticulated  from  the 
carpus),  the  distal  fragment  is  raised  from  its  bed,  and, 
beginning  at  the  upper  end,  its  palmar  surface  is  carefully 
separated  from  the  soft  par t s . 

In  disarticulation  of  the  fifth  metacarpal,  the  incision 
should  be  made  along  the  inner  border  of  the  hand,  and 
e;i fried  down  to  the  bone  between  the  skin  and  the  abduc- 
tor_minimi  di^iti_  rather  than  through  the  fibers  ot  the 
latter  (Fig.  28,  F).  This  gives  easier  access  to  the  palmar 
ligaments  uniting  the  bone  to  the  carpus.  The  lower  end 
of_tlic  incision  should  form  :i  [qqd  with  i ts  center  iii  the 
interdigita)  vj  -!j.  and  it-  p  >inl  on  the  line  of  the  knuckle. 

AMPUTATION   AT   THE   WRIST. 

(Radio-carpal  Disa  rticulation.) 

Circular  Method  (Fig.  28,  G). — While  an  assistant  re- 
tracts the  skin  upon  the  forearm,  the  operator  -weeps  his 
knife  transversely  around  the  wrist,  half  an  ineh_helow 
the  point  of  the  styloid  process  of  the  radius.  The  skin 
and  as  much  cellular  tissue  as  possible  are  divided  and 
dissected  back  as  far  a-  the  joint,  which  is  then  opened 
by  entering  ETie   poiul  of  the  knife  jusf  below  the   styloid 


AMPUTATION  OF  THE   FOREARM. 


-'.) 


process  of  the  radius,  and  the  disarticulation  completed 
while  the  hand  is  drawn  firmly  away  from  the  arm. 

Antero-posterior  Flaps. — The  absence  of  muscular  fi- 
bers at  the  wrist  deprives  this  method  of  most  of  the  ad- 
vantages which  it  offers  at  other  points,  and  the  projec- 
tion on  the  palmar  surface  of  the  trapezium  and  pisiform 
bones  renders  its  execution  difficult  and  makes  it  prac- 
tically identical  with  the  circular  method  supplemented 
by  lateral  incisions.  It  should  be  reserved  for  cases  in 
which  the  skin  is  s(,  infiltrated  that  it  cannot  be  readily 
dissected  back. 

A,n  incision  curved  downward^  is  carried  across  the 
back  of  the  wrist  from  one  styloid  process  to  the  other, 
the  flap  dissected  up,  the  hand  flexed  forcibly,  the  exten- 
sor tendons  divided,  the  joint  opened  beneath  them  and 
the  palmar  flap,  which  should  extend  as  far  down  as  the 
base  of  the  metacarpal  bones,  cut  from  within  outward. 

Or  the  palmar  flap  muv  be  made  from  without  inward, 
or  by  transfixion,  before  the  joint  has  been  opened. 

External  Lateral  Flap. — Dubrueil '  (Fig.  28,  H).  The 
hand  is  pronated  and  the  operator  makes  a  curved  inci- 
sion,  which,  beginning  on  the  dorsal  aspfvt  a  quarter  of 
an  inch  below  the  radio-carpal  articular  line,  at  the  junc- 
tion of  the  outer  and  middle  thirds,  passes  downward, 
eros-es  the  outer  side  of  the  first  metacarpal  bone  at  its 
center  and  returns  to  a  point  on  the  palmar  surface  op- 
posite that  at  which  it  began.  Its  two  ends  are  then 
joined  by  a  transverse  incision  passing  around  the  inner 
side  below  the  end  of  the  ulna.  The  external  flap  ls  dis- 
sected up,  the  joint  opened  at  the  radial  side  and  the  dis- 
a  rticulation  completed . 


AMPUTATION  OF  THE  FOREARM. 
The  forearm  may  be  divided,  with  reference  to  sur- 
gical considerations,  into  upper,  middle,  and  lower  thirds. 
It~  shape  is  cylindrical  near  the  elbow  and  gradually 
Battens  and  narrows  toward  the  wrist.  The  lower  half  of 
the  radius  and  the  whole  length  of  the  ulna  are  subcu- 
1  M<?decine  '  >peratoire,  p.  171. 


AMPUTATIONS. 

taneous.  The  coverings  of  the  lower  third  are  composed 
almost  exclusively  of  skin  and  tendons,  while  thick  mus- 
cular masses  cover    the  upper  two-thirds,  especially  on 

thf  anterior  aspect.  The  absence  of  suitable  coverings 
in  the  lower  third  and  the  presence  there  of  so  many 
synovial  sheaths,  the  inflammation  of  which  might  give 
rise  to  dangerous  complications,  led  older  surgeons  to  ad- 
vise strongly  against  amputating  at  this  part.  But  these 
objections  have  been  greatly  diminished  by  modern  meth- 
ods of  treatment  which  favor  rapid  uneventful  healing 
and  so,  unhampered  by  any  other  considerations  than 
those  established  by  the  extent  of  the  injury  or  disease 
that  necessitates  the  operation,  we  are  free  to  save  as 
much  as  possible  of  the  limb.  Every  additional  inch 
adds  to  the  usefulness  of  the  stump. 

For  the  reasons  stilted,  the  only  method  applicable  to 
the  lower  third  is  the  circular  one,  and  if  the  conicity  of 
the  limb  or  the  infiltration  of  the  parts  should  otherwise 
render  it  impossible  to  carry  the  dissection  of  the  cutane- 
ous sleeve  to  a  sufficient  height,  the  circular  incision  must 
be  supplemented  by  a  short  longitudinal  one  in  front. 
Tin  divisiuu_oi'  the  tendons  should  be  on  the  same  level 
with  that  of  the  hone,  and  is  best  accomplished  by  pass- 
ing the  knife  under  them,  and  cutting  directly  outward. 

In  the  middle  third  the  difficulty  of  dissecting  a  cuta- 
ueous  sleeve  is  likely  to  be  still  greater,  and  has  led  to 
general  rejection  of  the  circular  method.  As  lateral  flaps 
are  Impossible,  and  the  bone-;  have  a  tendency  to  project  at 
the  angles  ifantero-posterior  flaps  are  made,  it  is  best  to  use 
short  lateral  skin  Maps  with  short  muscular  fla^g  by  trans- 
fix ion  ( Ti  I  lau  x  ),(M^_dmihirdTvisioi^ 
s i ycly  higher  le vols,  and  still  higher  division  of  the  bones. 

High  up^in  the  upper  third,  where  the  position  of  the 
bones  is  more  central,  and  thick  muscular  nia.-.-es  lie  upon 
the  sides,  the  short  flaps  should  be  lateral 

AMPUTATION  AT   THE  ELBOW-JOINT. 
The  irinde^  to  the  articulation  are  the  opitroohloa  on  the 

inner,  the    epicoudyje  and    the    head  of  the    radju-  on   the 


AMPUTATION  AT  THE  ELBOW-JOINT.  81 

outer  side.  The  smooth  rounded  prominence  formed  by 
the  latter  can  be  readily  felt  about  half  an  inch  below  the 
cpieondyle  ;  and  the  interarticnlar  ling  starting  from  it  ft**"  fl**~* 
passes  at  first  transversely  and  then  downward  and  in,r 
ward  toward  a  point  an  inch  below  the  epi trochlea,  and 
forms  an  angle,  opening-  inward,  with  the  transverse 
diameter  of  the  lower  end  of  the  humerus.  It  is  there- 
fore unnecessary  to  expose  the  epicondvle  and  epitrochjen. 
in  disarticulating  ;  and  these  relative  positions  should  be 
constantly  kept  in  mind  during  the  operation.  The  skin 
is  freely  movable  in  front,  but  is  adherent  to  the  ulna 
behind. 

The  methods  in  common  use  are  the  anterior  flap, 
lateral  Hap,  and  circular. 

Anterior  Flap. — The  joint  may  be  opened  (a)  from  be- 
hind, or  (b)  from  in  front. 

'/.  From  Behind.  (SidUlot.) — The  forearm  is  flexed, 
and  an  incision,  slightly  convex  downward  and  interesting 
only  the  posterior  third  of  the  circumference,  is  made  one 
and  a-half  inches  below  the  tuberosities  of  the  humerus. 
The  skin  is  dissected  up  to  the  tip  of  the  olecranon,  the 
tendon  of  the  triceps  clivkled,  the  point  of  the  knife 
passed  into  the  joint  and  carried  first  to  one  side  and  then 
to  the  other,  cutting  the  posterior  and  lateral  ligaments. 
A  longitudinal  incision  two  and  a-half  inches  longiis  then 
carried  downward  from  the  outer  end  of  the  first,  the 
forearm,  still  flexed,  is  pressed  backward  and  inward,  and 
the  disarticulation  readily  completed  by  passing  the  knife 
through  the  joint,  and  cutting  down  and  out  on  the  an- 
terior aspect  while  the  skin  is  forcibly  retracted. 

b.  From  ix  Front.  (Fig.  29,  J.')— The  flap,  may  be 
made  by  transfixion,  or  from  without  inward  ;  in  either 
case  it  should  be  at  least  three  inches  long,  and  its  base 
-hoiild  be  parallel  to  and  three-quarters  of"an  inch  below 
a  line  drawn  through  the  epicondyle  and  the  epitrochlea. 
The  posterior  incision  should  be  slightly  convex  down- 
ward,  and  should  begin  and  end  at  the  same  points  as  the 
anterior  one  ;  it  is  made  from  without  inward,  not  by 
transfixion. 


82 


AMrUTATIOSS. 


The  head  of  the. radius  is  then  sought  foiyand  the  joint_ 
opened  by  entering  the  knife  between  it  and  the  humerus 
and  completely  dividing  the  external  lateral  ligament. 
The  <ap.-ulc.Js  divided  in  front  by  passing  the  point  of 
the  knife  along  the  edge  of  the  ulna  over  the  eoronoid 
process  to  the  internal  lateral  ligament,  which  should  be 
cut  as  high  as  possible,,  The  olecranon  is  disengaged 
from  the  humerus  by  drawing  it 
Fig.  29.  down    forcibly,    the    attaehment_^pf 

the  triceps  divided,  the  knife  passed 
behind  the  bone,  and  the  remaining 
tissues  divided  from  within  outward. 
Lateral  Flap.  (Fig.  29,  B.)— An 
e^ernnl  -flap  four  inches  long  is 
a  made  by  transfixion  from  a  pointjn 
the  median  line  in  froirfc,  a  finger's 
breadth  below  the  bend  of  the  el- 
bow ;  or  from  without  inward  by  an 
incision  beginning  at  the  same  point 
and  ending  half  an  inch  higher  on 
the  posterior  face  of  the  ulna.  A 
second  incisionals  made  transversely 
across  the  inner  side  of  the  arm 
aboil t  an  inch  below  the  upper  cim] 
of  the  first.  The  radio-humeral  joint 
is  opened  and  the  disarticulation 
completed  as  before. 

Instead  of  a  single  external  flap, 
two  lateral  flaps  may  be  made,  but 
the  external  should  be  half  an  inch 
longer  than  the  internal  one. 
Circular.  (Fig.  29,  ('.) — An  inci- 
sion, transverse  or  a  little  lower  on  the  outer  than  on  the 
inner  side,  is  made  about  the  limb  three  and  a-half  inches 
below  the  epitrochlea  and  carried  down  to  the  enveloping 
fascia;  the  cutaneous  sleeve  is  dissected  up  for  abou tan 
inch  and  the  muscles  divided  transversely  at  its  baseTTliey 
are  then  retracted  forcibly  by  an  assistant  BO  as  to  form  a 
•  •one  with  its  apex  directed  downward  and  the  deep   inusj- 


Amputation  al  the  elbow- 
joint.  .1.  Anterior  Bap.  B. 
External  flap.  C.  Circular 
method, 


AMPUTATION  AT  THE  SHOULDER-JOINT.         83 

eles  of  the  anterior  aspect  are  again  divided  transversely 
oil  a  level  with  the  radio-humeral  articulatio.n,  the  exter- 
nal lateral  ligament  being  included  in  the  incision  and 
the  joint  thereby  opened.  The  disarticulation  is  com- 
pleted as  before  described. 

AMPUTATION  OF   THE  ARM. 

This  may  be  performed  at  any  point  below  the  attach- 
ments of  the  muscles  of  the  axilla.  Disarticulation  at- 
the  shoulder  is  preferable  to  amputation  in  continuity 
above  these  attachments.  As  the  bone  is  centrally  placed 
and  Avell  covered  on  all  sides,  any  one  of  the  usual  meth- 
ods of  amputation  may  be  employed.  As  a  general  rule 
the  biceps  should  be  divided  at  a  lower  level  than  the 
other  muscles  because  it  is  not  adherent  to  the  humerus 
and,  therefore,  retracts  more  than  the  others.  The  cir- 
cular incision  should  be  half  an  inch  lower  on  the  inner 
than  on  the  outer  si<|<\  In  muscular  subjects  flaps 
should  be  cut  rather  thin  and,  when  possible,  it  is  better 
that  the  main  artery  should  be  in  the  posterior  flap.. 

AMPUTATION  AT  THE  SHOULDER- JOINT. 

General  Considerations. — The  exposed  position 
and  great  accessibility  of  the  head  of  the  humerus  have 
led  to  the  suggestion  of  many  operative  methods,  most  of 
which  can  be  performed  with  much  ease  and  regularity 
upon  the  cadaver  and  yield  good  results  in  actual  prac- 
tice. But  as  the  operation  is  usually  rendered  necessary 
by  malignant  disease  or  compound  fracture  of  the  hu- 
merus, under  circumstances  which  make  it  very  difficult,  if 
not  impossible,  to  follow  regular  methods,  it  is  more  im- 
portant to  be  familiar  with  the  anatomy  of  the  parts  and 
the  general  principles  governing  all  the  methods  than 
with  the  details  of  the  different  ones. 

The  size  of  the  axillary  artery  and  the  difficulty  of  effi- 
ciently compressing  the  subclavian  make  the  mnnagempi]t 
of  the  artery  an  element  of  prime  importance  in  this  opera- 
tion.    The  joint  should  be  approached  from  the  outer  si<le, 


i  i. 


Si  AMPUTATIONS. 

and  the  artery  divided  from  within  outward  after  disarticu- 
lation, an  assistant  passing  his  thumb  into  the  wound  above 
the  knife  and  compressing  the  vessel  before  it  has  been  cut. 
Or  the  artery  may  be  exposed  during  the  operation  and 

tied  before  it  is  cut. 

Pressure  upon  the  subclavian  may  be  made  by  the  thumb 
of  an  assistant  standing  behind  the  patient,  or  by  a  rubber 
cord  tightly  encircling  the  axilla,  scapula,  and  clavicle. 
To  prevent  slipping  of  the  cord  a  long  mattress-needle  is 
sometimes  introduced  near  the  tip  of  the  coracoid  process, 
carried  through  the  capsule  of  the  joint,  grazing  the  head 
of  the  humerus,  and  made  to  emerge  posteriorly  near  the 
axillary  border  of  the  scapula.  The  cord  is  then  applied 
circularly  on  the  proximal  side  of  this  skewer. 

Wyeth1  uses  two  pins,  one  passing  through  the  anterior 
axillary  fold  and  piercing  the  tendon  of  the  pectoralis 
major  from  above  downward,  the  other  from  before  back- 
ward just  below  the  acromion  process  through  the  fibers  of 
the  deltoid. 

The  subsequent  retraction  of  the  pectoralis  major  and 
latissimus  dorsi  tends  to  gaping  of  the  wound  and  the  for- 
mation of  a  broad,  unsightly,  triangular  cicatrix.  This 
must  be  met  by  retaining  all  the  skin  for  the  first  two  or 
three  inches  in  the  flaps,  not  allowing  the  incisions  to 
diverge  from  one  another  until  the  end  of  the  flap  is  nearly 
reached.  This  precaution  also  insures  ample  covering  for 
the  projecting  acromion.  The  outer  flap  should  comprise 
the  entire  thickness  of  the  deltoid  so  that  the  gap  left  by 
the  head  of  the  humerus  may  be  properly  filled,  and  it 
should  lie  dissected  up  close  to  the  bone  so  as  to  avoid  in- 
jury to  the  trunk  of  the  posterior  circumflex  artery. 

In-tead  of  attempting  to  separate  the  capsule  at  its  at- 
tachment to  the  upper  edge  of  the  glenoid  cavity  by  pass- 
ing the  |>'>int  of  the  knife  under  the  acromion,  it  is  better 
to  divide  it  near  its  center  by  drawing  the  edge  of  the 
knife  across  the  upper  surface  of  the  head  of  the  humerus; 
and  in  all    incisions   beginning   between  the  acromion  and 

coracoid  process  the  point  of  the  knife  should  be  passed 
'Jour.  Am.  Med.  A--"'..  Februan  7,  L891. 


A.vrrr  \rif>\  at  tin-:  SBOULDEH-JOTNT.        85 

directly  down  to  the  humerus  so  as  to  divide  the  strong 
fibrous  arch  connecting  the  two  processes. 

Oval  Method  (Baron  Larrey).  (Fig.  30,  A). — A 
longitudinal  incision  involving  nil  the  tissues  down  to  the, 
bone  is  made  on  the  outer  aspect  of  the  shoulder  from  th,e 
edge  of  the  acromion  to  a  point  one  inch  below  the  neck 
of  the  humerus,  and  an  oval  one  interesting  the  skin  only 
is  then  carried  from  its  lower  end  around  the  arm,  cross- 
ing its  inner  side  about  an  inch  below  .the  border  of  t.l,)(» 
axilla.  The  flaps  thus  marked  out  are  dissected  up,  the 
anterior  one  carefully,  until  the  tendon  of  the  pectoralis 
major  is  exposed  and  divided  close  to  its  insertion,  the 
posterior  one  more  boldly,  but  close  to  the  bone,  so  as  to 
avoid  injury  to  the  trunk  of  the  circumflex  artery.  The 
capsule  is  freely  divided  across  the  head  of  the  humerus, 
the  arm  rotated  inward  and  then  outward,  so  as  to  facili- 
tate division  of  the  tendons  of  the  articular  muscles, 
which  is  best  accomplished  by  cutting  directly  upon  the 
tuberosities,  the  humerus  thus  liberated  is  thrown  out- 
ward by  adducting  the  elbow,  the  knife  is  passed  behind 
it  and  carried  down  and  out  through  the  cutaneous  inci- 
sion  on  the  inner  side,  while  an  assistant  compresses  the 
artery  in  the  wound. 

After  cutting  through  the  tendon  of  the  pectoralis 
major,  Yemeni  1  isolates  the  biceps  and  coraco-brachialis 
with  his  lingers,  divides  them,  seeks  for  the  artery,  and 
ties  it  rather  high  up  before  continuing  the  operation. 

It  is  sometimes  not  easy  to  reach  and  divide  the  broad 
tendon  of  the  subscapulars  ;  and  when  the  humerus  is 
broken  it  is,  of  course,  impossible  to  use  it  as  a  lever  to 
force  the  head  of  the  bone  out  of  the  socket,  and  this  part 
of  the  operation  may  thereby  be  rendered  somewhat  diffi- 
cult. This  and  the  hemorrhage  from  the  branches  of 
the  posterior  circumflex  are  the  principal  objections  to 
this  method,  which  has,  nevertheless,  yielded  excellent 
results. 

The  articulation  is  uncovered  more  freely  by  any  of  the 
double  flap  methods  in  which  an  external  flap  is  fashioned 
out  of  the  deltoid  muscle.     Of  these  the  Lisfranc  method 


Sfi 


AMPITATlOXs. 


may  be  taken  as  the  type,  premising  only  thai  while  the 
opening  of  the  articulation  by  transfixion  is  very  easy  of 
execution  upon  the  cadaver,  it  is  sometimes  impossible 
upon  the  living  subject,  and  inapplicable  to  eases  of  ma- 
lignant disease  of  the  humerus.  Under  such  eirenni- 
stances  the  flaps  must  be  made  by  dissection  from  without 
inward. 

Double  Flap  Method  (Lisfranc).     (Fig.  30,  B.) — Right 
shoulder.      While  the  arm  is  abducted  the  surgeon  enters 


Fk 


30. 


Disarticulation  al  the  shoulder.    A.  Oval  method.     /.'.  Method  by  double  Saps 


the  point  of  a  two-edged  amputating  knife  at  the  outer  side 
of  the  eoracoid  process,  carries  it  across  the  outer  aspect  of 
the  head  of  the  humerus,  and  brings  it  out  a  little  below 
the  posterior  border  of  the  acromion,     lie  then  raises  the 

fibers  of  the  deltoid  with  his  left  hand,  works  the  knife 
downward  around  the  head  of  the  bone,  and  cuts  a  broad 

flap  about  five  inches  long.     In  this  manoeuvre  the  joint 

should  be  opened    :it    its    upper    part,  the    tendons    of  the 

siipra-spinatns  and  long  head  oft  he  biceps  entirely  divided, 
and  those  of  the  subscapularis  and   infra-spinatus  partly 

divided.      The   arm    is    then    adducted,    the    knife    passed 


AMPUTATION  AT  THE  SHOULDER-JOINT. 


87 


and  a  loiio-  innei 


fla 


Fig.  31. 


through  the  joint  to  the  inner  side 
cut  from  within  outward. 

Left  shoulder.  The  knife  is  passed  in  the  opposite 
direction,  that  is,  from  below  the  acromion  behind  to  the 
eoracoid  process  in  front,  and  the  operation  completed  as 
on  the  right  side. 

Spence's  Method. — Prof.  Spence  introduced  a  method, 
for  which  he  claims  the  following  advantages  :  1st.  The 
better  form  of  the  stump.  2d.  The  division  of  the  pos- 
terior circumflex  artery  only  in  its 
terminal  branches  in  front.  3d.  The 
great  ease  with  which  disarticulation 
can  be  accomplished.  Another  advan- 
tage is  that  an  operation  for  excision 
of  the  head  of  the  humerus  can  be 
easily  transformed  into  a  disarticula- 
tion by  its  means,  should  that  be  found 
necessary. 

He  describes  the  operation  as  fol- 
lows (Fig.  31)  :x  "  The  arm  being 
slightly  abducted,  and  the  humerus 
rotated  outward,  I  cut  down  upon  the 
head  of  the  humerus  immediately  ex- 
ternal to  the  eoracoid  process,  and 
carry  the  incision  down  through  the 
clavicular  fibers  of  the  deltoid    and 

v  •  i  ,.ii    x  l         Disarticulation    at     the 

pectoralis  major  muscles,  till  1  reach  shoulder.  Spence's  method, 
the  humeral  attachment  of  the  latter 
muscle,  which  I  divide.  I  then,  with  a  gentle  curve, 
carry  my  incision  across  and  fairly  through  the  lower 
fibers  of  the  deltoid  toward,  but  through,  the  posterior 
border  of  the  axilla.  Unless  the  textures  be  much  torn,  I 
next  mark  out  the  line  of  the  lower  part  of  the  inner 
section  by  carrying  an  incision  through  the  skin  and  fat 
only,  from  the  point  where  my  straight  incision  terminated, 
across  the  inside  of  the  arm  to  meet  the  incision  at  the 
outer  part.  If  the  fibers  of  the  deltoid  have  been  thor- 
oughly divided,  the  flap,  together  with  the  posterior  cir- 
1  Lectures  on  Surgery,  2d  ed.,  Vol.  II.,  p.  662.  Edin.,  1876. 


88  AMPUTATIONS. 

cuniflex  artery,  can  be  easily  separated  by  the  point  of 
the  finger  from  the  bone  and  joint,  and  drawn  upward  and 
backward  so  as  to  expose  the  head  and  tuberosities  with- 
out further  nse  of  the  knife.  The  tendinous  insertions  of 
the  capsular  muscles,  the  long  head  of  the  biceps,  and  the 
capsule  are  next  divided  by  cutting  directly  on  the  bone. 
Disarticulation  is  then  accomplished,  and  the  limb  removed 
by  dividing  the  remaining  soft  parts  on  the  axillary  aspect. 
"  In  cases  where  the  limb  is  very  muscular  I  dissect 
the  skin  and  fat  from  the  deltoid  at  the  lower  part  and 
then  divide  the  muscular  fibers  higher  up  by  a  second  in- 
cision, so  as  to  avoid  redundancy  of  muscular  tissue." 

AMPUTATION  OF  THE  ARM,  SCAPULA,  AND  PAET 
OR  ALL  OF   THE  CLAVICLE. 

Make  an  incision  along  the  outer  two-thirds  of  the 
front  of  the  clavicle  ;  carry  the  incision  through  the  peri- 
osteum. Divide  the  periosteum  transversely  at  the  inner 
angle  of  the  wound,  strip  it  as  far  as  possible  from  the 
middle  third  of  the  bone  and  saw  through  the  bone,  pref- 
erably with  Gigli  wire,  at  the  inner  end  of  this  denuded 
surface.  Raise  the  sawn  end  of  the  outer  fragment,  strip 
off  the  periosteum  from  its  deeper  surface  and  saw  it 
through  again  at  about  the  junction  of  the  outer  and  mid- 
dle thirds.  Through  the  gap  thus  made  the  great  vessels 
are  exposed  and  divided  between  separate  double  liga- 
tures for  each,  close  to  the  first  rib. 

A  second  incision  is  made  from  the  center  of  the  first 
downward  and  outward,  along  the  groove  between  the 
pectoral  and  deltoid  muscles,  to  the  junction  of  the  ante- 
rior axillary  fold  with  the  arm  ;  thence  across  the  inner 
surface  of  the  arm  to  the  junction  of  the  posterior  axillary 
fold  with  the  arm  and  thence  downward  and  inward  be- 
tween the  tens  major  and  latissimus  dorsi  to  the  inferior 
angle  of  the  scapula. 

The    skin    and    subcutaneous    tissue   over    the   anterior 

fold  of  the  axilla  is  raised  and  the  pectoralis  major  cw\ 

where  it  begins  to  become  tendinous. 

The  pectoralis  minor  is  severed  close  to  the  coracoid 


AMPUTATION  OF  PART  OH  ALL   OF  CLAVICLE.    89 

process  and  after  division  of  the  cords  of  the  brachial 
plexus  at  the  level  where  the  great  vessels  were  cut,  only 
the  muscles  attached  to  the  trunk  and  scapula  retain  the 
limb.  The  patient  is  then  turned  toward  the  opposite 
side.  Another  incision,  through  the  skin  and  subcutane- 
ous tissue,  is  carried  from  the  outer  end  of  the  first  cla- 
vicular incision  at  the  acromioclavicular  joint,  across  the 
spine  of  the  scapula  to  terminate  in  the  second  incision  at 
the  inferior  angle  of  the  scapula.  The  skin  and  subcu- 
taneous tissue  on  the  inner  side  of  the  incision  are  raised 

Fig.  :;•_'. 


Amputation  of  the  arm,  scapula  ami  part  or  all  of  the  clavicle.  (The  dotted 
lines  represent  the  part  of  the  incision  which  lies  on  the  posterior  aspect  of  the 
body.)    (Treves.) 


sufficiently  to  permit  division  of  the  clavicular  and  scapu- 
lar attachments  of  the  trapezius. 

Then,  starting  at  the  outer  end  of  the  superior  border 
of  the  scapula,  the  omohyoid,  levator  anguli  scapulae, 
rhomboideus  minor  and  major,  and  the  serratus  magnus 
are  divided  in  this  order  close  to  the  bone,  and  the  limb 
detached. 

The  early  ligation  of  the  subclavian  vessels  prevents 
any  great  loss  of  blood.  The  sutured  wound  forms  an  ob- 
lique line  running  from  above  downward,  outward,  and 
backward. 


90  AMPUTATIONS. 

AMPUTATION  OF  THE  TOES. 

The  different  phalanges  of  the  toes  may  be  removed  by 
the  same  methods,  and  at  the  same  points,  as  those  of  the 
fingers,  but  experience  has  shown  that,  except  for  the 
great  toe,  it  is  better  to  disarticulate  at  the  metatarso- 
phalangeal joint,  the  preservation  of  a  portion  of  a  toe 
being  a  source  of  discomfort  rather  than  an  advantage. 
In  the  case  of  the  great  toe  it  is  desirable  to  save  as  much 
as  possible,  and  amputation  in  continuity  is  to  be  preferred 
to  disarticulation.  In  all  operations  upon  the  foot  the  in- 
cisions should  be  so  arranged  that  the  cicatrices  will  not 
occupy  the  plantar  surface.  It  must  be  remembered  that 
the  web  between  the  toes  lies  far  below  the  metatarso- 
phalangeal joint. 

The  incision  should  be  commenced  on  the  dorsal  sur- 
face a  little  above  the  joint,  carried  directly  down  the 
bone  for  about  an  inch,  and  then,  diverging  abruptly  into 
the  web,  straight  across  in  the  digito-plantar  fold,  and 
back  on  the  other  side  to  the  point  of  divergence  (Fig. 
33,  A).  If  the  strong  flexor  tendons  have  been  com- 
pletely divided  it  will  then  be  found  easy  to  disarticulate 
by  entering  the  knife  at  the  side  of  the  joint.  This  oval 
incision  is  better  than  the  two  lateral  semilunar  flaps,  be- 
cause its  cicatrix  does  not  extend  into  the  sole  of  the  foot. 

The  distal  phalanx  of  the  great  foe  may  be  removed  ac- 
cording to  the  methods  described  for  the  corresponding 
part  of  the  thumb  and  fingers  (p.  75). 

Disarticulation  of  the  great  toe  at  the  metatarso-phalan- 
geal  joint  may  be  done  according  to  the  method  just  de- 
scribed  for  the  other  toes,  or  with  a  large  internal  flap. 
In  the  latter  case  an  incision  (Fig.  34,  A)  is  begun  on 
the  outer  side  of  the  extensor  tendon  just  below  the  joint, 
and  carried  straight  down  to  the  head  of  the  first  phalanx. 
From  its  lower  end  a  transverse  incision  is  carried  around 
the  inner  Bide  of  the  toe  to  the  outer  edge  of  the  flexor 
tendon,  and,  the  toe  being  then  forcibly  extended,  a 
plantar  excision  is  carried  from  the  end  of  the  trans- 
verse incision  (Fig.  34,  B),  along  the  outer  side  of  the 
flexor  tendon  to  the  digito-plantar  fold,  and  thence  trans- 


AMPUTATION  OF  THE  TOES, 


91 


versely  around  the  outer  side  of  the  toe  to  rejoin  the  firsl 
incision  near  its  center. 

The  internal  Hap  is  then  dissected  from  below  upward, 
the  extensor  tendon  divided  high  up,  the  lateral  liga- 
ments divided,  the  knife  passed  through  the  joint,  and  the 
remaining  soft  parts  cut  from  within  outward. 

The  same  incisions  made  somewhat  lower  down  may  be 


Fig.  33. 


Fro.   .'5-1. 


-A 


Amputation  nf  the  great  toe. 

used  for  amputation  in  contin- 
uity, but  usually  the  shape  and 
position  of  the  flaps  will  be  de- 
termined by  the  nature  and  ex- 
tent of  the  injury  which  makes 
the  operation  necessary. 

Amputation  of  the  Two  Adjoin- 
ing   Iocs. — The    dorsal    incision 
should    begin   in  the   intermeta- 
tarsal  space  just  above  the  level 
of  the  joint  (Fig.  33,  B),  extend 
down  to  the  beginning  of  the  web, 
diverge  obliquely  to  the  adjoining- 
web,  cross  the  plantar  surface  in 
the  digito-plautar    fold  of  both 
toes,  and  return  through  the  other 
adjoining  web  to  the  point  of  divergence.     Each  toe  is  then 
removed  separately  after  division  of  its  tendons  and  lateral 
ligaments. 

AMPUTATION  OF  A  METATARSAL  BONE. 
Amputation  in  continuity  is  much  to  be  preferred  to 
disarticulation  on  account  of  the  extent  of  some  of  the 


Amputation    of    the    toe 
metatarsal  bones. 


ami 


92  i  IMPUTATIONS. 

synovia]  sacs,  the  attachments  of  certain  muscles,  and  the 
importance  of  Mime  of  the  bones  in  preserving  the  rela- 
tions of  the  other-.  The  synovial  sac  which  forms  part 
<>f  the  articulation  between  the  first  cuneiform  and  first 
metatarsal  hones  is  isolated  from  the  others,  bnt  the  at- 
tachment of  the  peroneus  longns  to  the  base  of  the  latter 
bone  renders  its  preservation  especially  important.  There 
is  also  a  separate  synovial  sac  for  the  articulation  between 
the  cuboid  and  the  fourth  and  fifth  metatarsals.  The  base 
of  the  fifth  metatarsal  is  easily  recognized  by  the  promi- 
nence which  it  forms  on  the  outer  side  of  the  foot;  that 
of  the  first  metatarsal  is  three-fourths  of  an  inch  anterior 
to  the  other,  and  is  the  first  prominence  encountered  by 
the  finger  when  it  is  passed  from  before  backward  along 
the  inner  side  of  the  bone. 

The  incision  begins  on  the  dorsal  aspect  at,  or  a  little 
below,  the  point  at  which  the  bone  is  to  be  divided,  is 
carried  down  well  below  the  metatarso-phalangeal  joint 
(Fig.  •'!.;,  C),  diverges  into  the  web,  crosses  the  plantar 
surface  in  the  digito-plantar  fold,  and  returns  through  the 
other  web  to  the  point  of  divergence.  A  short  transverse 
incision  is  made  through  the  skin  at  its  upper  end  to  facil- 
itate division  of  the  bone,  which  is  then  effected  with 
cutting  pliers  or  a  Gigli  wire  after  the  soft  parts  have 
been  separated  on  both  sides.  The  toe  is  then  pressed 
backward,  the  cut  end  of  the  bone  raised,  the  knife  passed 
behind  it,  and  the  operation  completed  by  cutting  from 
within  outward.  The  first  and  fifth  metatarsal  bones 
should  be  cut  obliquely  so  ;i>  to  diminish  the  prominence 

of  the  Stump. 

For  disarticulation  oj  the  first  <>,■  fifth  metatarsal  hones 
the  only  modification  Deeded  is  to  begin  the  incision  at  a 
correspondingly  higher  point — at  or  a  little  below  the 
tarso-metatarsal  join!  (Fig.  •'!•'!,  I>).  After  the  flaps  have 
been  dissected  up,  the  .joint  i>  opened  by  dividing  the 
dorsal  and  interosseous  ligaments,  and  the  bone  raised  and 
separated  from  the  remaining  soft  parts. 


LISFRANCS  nil  ///.)'>   AMPUTATION. 


93 


Fig.  35. 


DISARTICULATION  OF   ALL  THE  METATARSAL 
BONES.      TARSOMETATARSAL  DISAR- 
TICULATION;   LISFRANCS   OR 
HEY'S  AMPUTATION.) 

The  position  and  general  direction  of  the  tarso-metatar- 
sal  articulations,  a-  well  as  the  peculiarity  presented  by  the 
base  of  the  second  metatarsal  bone, 
are  sufficiently  well  shown  in  Fig. 
35  to  render  a  detailed  description 
unnecessary.  The  guides  to  the  ar- 
ticulation are  the  projecting  liases  of 
the  first  and  fifth  metatarsal  bones. 

The  skin  being  retracted  by  an 
assistant,  the  surgeon  makes  with  a 
scalpel  a  curved  incision  across  the 
dorsum  of  the  foot  from  the  base  of 
the  fifth  to  the  base  of  the  first  meta- 
tarsal bone.  (For  the  left  foot  the 
direction  of  this  incision  should  be 
reversed.)  The  incision  should  in- 
volve the  skin  only ;  its  center 
should  lie  half  an  inch  or  more 
below  the  center  of  the  line  of  the 
articulations,  and  it  should  begin 
and  end  upon  the  sides  of  the  foot 
at  their  junction  with  the  sole. 
(Fig.  35.) 

A  plantar  flap  should  then  be 
marked  out  by  a  curved  incision 
be^inninu-  and  ending  at  the  same 

, ,        r,  5  ...  .4.  Lisfranc's  amputation.    A*, 

points  a.-  the  first  and  CrOSSing  the    Chopart's amputation. 

sole    near  the  origin   of   the  toes. 

The  dorsal  -kin  flap  i-  then  dissected  back  to  the  line  of 
the  articulation,  the  tendons  and  muscular  fibers  of  the 
short  extensor  divided,  the  joints  between  the  fifth, 
fourth,  and  third  metatarsals,  and  the  corresponding 
bones  of  the  tarsus  opened  successively  from  the  outer 
side,  and  that  between  the  first  metatarsal  and  first  cunei- 
form  from   the   inner  side.     With  the  point  of  the  knife 


94  AMPUTATIONS. 

directed  transversely  across  the  dorsal  aspect  of  the 
base  of  the  second  metatarsal,  the  joint  between  that  bone 
and  the  second  cuneiform  is  sought  from  below  upward, 
and  after  it  has  been  found  and  opened  the  interosseous 
Ligaments  uniting  the  second  to  the  first  and  third  meta- 
tarsals are  divided  by  thrusting  the  point  of  the  knife 
well  down  between  them,  the  flat  of  its  blade  being  held 
parallel  to  the  long  axis  of  the  foot,  and  the  toes  being 
forcibly  depressed. 

After  the  bone  has  been  thus  disengaged,  the  knife  is 
passed  through  the  articulation,  and  the  plantar  flap  cut 
from  within  outward. 

Modifications. — The  plantar  flap  may  be  cut  (1)  from 
without  inward,  or  (2)  by  transfixion,  before  the  articula- 
tions have  been  opened.  Instead  of  disarticulating  it,  the 
base  of  the  second  metatarsal  may  be  cut  off  with  pliers 
or  a  saw  and  left  in  place.  Hey  sawed  off  the  projecting 
part  of  the  first  cuneiform  after  disarticulating,  but  this 
weakens  the  attachment  of  the  tibialis  anticus,  a  disad- 
vantage which  is  not  offset  by  the  improvement  in  the 
outline,     f 

MEDIO-TARSAL  OR  CHOPARTS  AMPUTATION. 

This  name  is  given  to  the  operation  of  disarticulation 
through  the  joints  formed  by  the  astragalus  and  calcaneuni 
behind,  the  scaphoid  and  cuboid  in  front.  The  guides  to 
the  joint  are  the  tubercle  of  the  scaphoid  on  the  inner 
side  of  the  foot,  the  head  of  the  astragalus  on  the  dorsum 
and  the  anterior  end  of  the  calcaneum  on  the  outer  bor- 
der. The  first  named  is  one-eighth  of  an  inch  in  front  of 
the  articulation  and  is  the  firsl  bony  prominence  found 
on  drawing  the  linger  from  the  inner  malleolus  forward 
along  the  side  of  the  foot  ;  the  sharp  edge  of  the  second 
can  be  readily  felt  when  the  anterior  portion  of  the  foot 
i-  forcibly  depressed  ;  the  latter  can  usually  be  made  out 
by  adducting  the  toes  and  inverting  the  sole,  nearly  mid- 
way between  the  tip  of  the  external  malleolus  and  the 
base  of  the  fifth  metatarsal  bone,  or  nearer  the  latter. 
When  the  foot  ie  .ii  righl  angles  with  the  leg,  the  ante- 


MEDIO  TARSAL   AMPUTATION. 


95 


rior  articular  surfaces  of  the  astragalus  and  calcaneum  arc 
in  the  same  plane,  cue  crossing  the  foot  transversely  at 

the  points  indicated. 

Operation.  (Figs.  35,  36,  37.) — The  surgeon  places 
the  thumb  and  forefinger  of  his  left  hand  upon  the  tuber- 
cle of  the  scaphoid  and  the  lower  and  outer  border  of  the 
cuboid,  with  the  palm  against  the  sole  and  makes  a 
curved  incision  from  one  to  the  other,  passing  an  inch 
anterior  to  the  head  of  the  astragalus  and  terminating 
on  each  side  just  below  the  level  of  the  joint.  The 
plantar  flap  is  next  marked  out  by  an  incision  beginning 

Fig.  36. 


Outer  side.     .1.  Chopart's  amputation.     B.  Syme's  amputation.     C.  Subastraga- 
loid  amputation.    D.  Line  of  section  of  the  bones  in  Syme's  amputation. 

and  ending  at  the  same  points  as  the  first  and  crossing 
the  sole  of  the  foot  four  or  five  finger-breadths  nearer  the 
toes.  The  dorsal  flap  is  next  dissected  up,  the  joint 
entered  at  either  of  the  points  mentioned  as  guides  (pref- 
erably between  the  astragalus  and  scaphoid  on  the  inner 
side,  after  dividing  the  tendons  of  the  tibiales),  opened 
widely  by  dividing  the  dorsal  and  interosseous  ligaments 
and  depressing  the  toes  and  the  plantar  flap  cut  from 
within  outward. 

Syme  preferred  to  make  the  plantar  flap  by  transfixion 
before  disarticulating. 


96 


AMPUTATIONS. 


The  anterior  tendons  should  be  stitched  to  the  deep 
tissues  and  the  dressing  should  keep  the  foot  in  extreme 
dorsal  flexion  at  the  ankle  in  order  that  these  tendons 
may  SO  unite  with  the  stump  that  their  muscles  will  pre- 
vent the  heel  from  being  raised  by  the  unopposed  action 
of  the  muscles  of  the  calf. 

SUB-ASTRAGALOID  AMPUTATION. 

(Figs.  36,  ( ',  and  37,  C.)  The  guides  to  this  operation 
are  the  tip  of  the  external  malleolus  and  the  head  of  the 


Fig 


I  inn  i-  side.     .1.'  Ihopart's 
loid  amputal  ion. 


imputal  ioi 


;ilil|iill;itiip|i. 


Subasl  raga- 


astragalus.  The  joint  must  be  entered  from  in  front  on 
the  fibular  side,  and  the  strong  interosseous  ligament  which 
forms  th<'  key  to  the  articulation  must  be  divided  step  by 
step  from  before  backward  and  inward.  The  posterior 
tibial  vessels  lie  behind  the  inner  malleolus,  and  must  be 
carefully  avoided. 

Beginning  at  the  outer  side  of  the  heel,  nearly  an  inch 
below  the  tip  of  the  external  malleolus,  an  incision,  extend- 
ing through  to  the  bone,  is  carried  straight  forward  to  the 
base  of  the  fifth  metatarsal  bom':  thence,  curving  forward 
across  the  dorsum  of  the  foot  to  die  base  of  the  first  meta- 


AMPUTATION  AT  THE  ANKLE-JOINT.  97 

tarsal  ;  thence  obliquely  backward  and  outward  across  the 
sole  of  the  foot  and  around  its  outer  border,  rejoining  the 
first  and  horizontal  part  of  the  incision  at  the  calcaneo- 
cuboid articulation.  The  soft  parts  must  he  separated 
from  the  outer  surface  of  the  calcanenm  and  cuboid  with 
division  of  the  peroneal  tendons,  the  dorsal  flap  dissected 
back  to  the  head  of  the  astragalus  and,  on  the  inner  side, 
beyond  the  tubercle  of  the  scaphoid,  thus  dividing  the 
tendon  of  the  tibialis  autieus  and  the  anterior  portion  of 
the  internal  lateral  ligament.  The  interosseous  ligament 
can  then  be  easily  reached  by  depressing  the  toes,  passing 
the  knife  between  the  astragalus  and  scaphoid,  and  cutting 
backward  and  inward  along  the  under  surface  of  the 
former.  The  soft  parts  mi  the  inner  side  are  then  sepa- 
rated from  the  calcanenm,  injury  to  the  vessels  being 
avoided  by  keeping  close  to  the  bone,  between  it  and  the 
tendon  of  the  flexor  communis,  the  foot  depressed,  and  the 
tendo  Achillis  divided.  This  last  is  a  very  difficult  part 
<>f  the  operation,  and  great  care  must  be  taken  to  keep  the 
edge  of  the  knife  close  to  the  bone,  s<>  as  not  to  cut  through 
the  skin. 

The  posterior  tibial  nerve  should  be  dissected  out  and 
cut  off  as  high  up  as  possible,  so  that  it  -hall  not  be 
pressed  upon  the  stump. 

Tripier  has  modified  this  by  leaving  the  upper  portion 
of  the  calcaneum  :  the  incision  is  the  same  ;  then  after  dis- 
articulating at  the  medio-tarsal  joint  and  freeing  the  lower 
surface  and  side-  of  the  calcanenm,  he  saws  through  the 
latter  horizontally,  the  cut  passing  from  the  postero- 
superior  to  tin-  antero-inferior  angle. 

AMPUTATION    AT    THE    ANKLE-JOINT. 

Syme's  Amputation,  Tibio-tarsal  Amputation.  (Figs. 
36,  37.  F>.) — Amputation  through  the  ankle-joint  by  the 
circular  method,  lateral  flap-,  or  a  long  anterior  flap  taken 
from  the  dorsum  of  the  foot,  as  proposed  by  Baudens,  did 
not  meet  with  favor,  because  the  delicacy  of  the  coverings 
or  the  vicious  position  of  the  cicatrix  rendered  the  stump 


98  AMPUTATIONS. 

practically  useless ;  and,  although  occasional  successes 
were  reported,  the  choice  still  lay  between  Chopart's 
operation  and  amputation  of  the  leg,  until  Prof.  Syme, 
in  1843/  showed  how  the  excellent  plantar  flap  could  be 
obtained.  About  the  same  time  Jules  Roux,  of  Toulon, 
met  the  same  indication  by  means  of  a  large  internal 
lateral  flap  carried  across  the  plantar  aspect  of  the  heel. 

By  greatly  restricting  the  necessity  for  amputation  of 
the  leg  this  operation  has  become  one  of  the  most  impor- 
tant and  frequently  performed  of  all  amputations.  The 
objections  urged  against  it,  and  the  unfavorable  results 
that  have  sometimes  followed  its  use,  seem  to  have  had 
their  origin  in  a  failure  to  understand  or  carry  out  all  the 
details  of  its  execution,  or  in  the  introduction  of  improper 
modifications.  Tt  has  seemed  desirable,  therefore,  to  re- 
produce here  Prof.  Syme's  directions  for  performing  it,  as 
published  in  1848,2  six  years  after  he  had  first  put  it  into 
practice. 

"  Succeeding  experience  taught  me  that  a  much  smaller 
extent  of  flap  than  had  originally  been  considered  neces- 
sary was  sufficient  for  the  purpose,  and  that  hence  the 
operation  could  not  only  be  simplified  in  performance,  but 
increased  in  safety  from  bad  effects. 

"  The  foot  being  placed  at  a  right  angle  to  the  leg,  a 
line  drawn  from  the  center  of  one  malleolus  to  that  of  the 
other,  directly  across  the  sole  of  the  foot,  will  show  the 
proper  extent  of  the  posterior  flap.  The  knife  should  be 
entered  close  up  to  the  fibular  malleolus,3  and  carried  to  a 
point  on  the  same  level  of  the  opposite  side,  which  will  be 
a  little  below  the  tibial  malleolus.  The  anterior  incision 
should  join  the  two  points  just  mentioned  at  an  angle  of 
4o°  to  the  sole  of  the  foot,  and  long  axis  of  the  leg.  In 
dissecting  the  posterior  flap,  the  operator  should  place 
the  fingers  of  his  left  hand  upon  the  heel,  while  the 
thumb  rests  upon  the  edge  of  the  integuments,  and  then 

1  Loud,  and  Kdin.  Monthly  Joiini.  of  Med.  Science,  Feb.,   L848. 

I  ontributionstothePath.  and  Practice  of  Surgery.    Edinburgh,  1848. 
'"The  tip  of  the  external  malleolus,  or  a  little    posterior  to  ii  ; 
rather  nearer  the  posterior  than  the  anterior   margin  of  die  hone." 
Byrne,  in  Lancet,  I  - 


AMPUTATION  AT  THE  ANKLE-JOINT.  99 

cut  between  the  nail  of  the  thumb  and  tuberosity  of  the 
os  calcis,  so  as  to  avoid  lacerating  the  soft  parts,  which  he 

at  the  same  time  gently,  but  steadily,  presses  back  until 
he  exposes  and  divides  the  tendo  Acliillis.1  The  foot 
should  be  disarticulated  before  the  malleolar  projections 
are  removed,  which  it  is  always  proper  to  do,  and  which 
may  be  most  easily  effected  by  passing  a  knife  round  the 
exposed  extremities  of  the  bones  and  then  sawing  off  a 
thin  slice  of  the  tibia  connecting  the  two  processes." 

Disarticulation  is  accomplished  by  opening  the  joint  in 
front  and  dividing  the  lateral  ligaments  by  entering  the 
point  of  the  knife  between  the  sides  of  the  astragalus  and 
the  malleoli. 

The  essentials  of  the  method,  as  pointed  out  by  the 
more  recent  Scotch  writers  (Lister,  Spence,  and  Bell),  are 
that  the  plantar  incision  should  run  from  the  tip  of  the 
external  malleolus  directly  across  the  heel,  should  on  no 
account  incline  forward,  and  should  terminate  at  least  half 
an  inch  below  the  tip  of  the  internal  malleolus  (behind 
and  below,  according  to  Lister).  In  case  the  heel  is  un- 
usually long  the  incision  may  even  incline  backward.  It 
is  not  only  unnecessary,  but  actually  dangerous,  to  make 
the  flap  longer  than  this,  for  it  then  becomes  impossible 
to  dissect  out  the  calcaneum  without  scoring  the  subcuta- 
neous tissue  in  all  directions,  and  increasing  the  chances 
of  sloughing.  If  the  incision  is  made  further  back  and 
carried  any  higher  on  the  inner  side,  the  posterior  tibial 
will  be  cut  before  its  division  into  the  two  plantar  arteries. 

Erichsen  and  Lister  both  claim  that  the  integrity  of  the 
posterior  tibial  is  not  of  great  importance,  the  vitality  of 
the  flap  depending  mainly  upon  anastomosing  branches  of 
high  origin  which  lie  quite  near  the  bone.  Erichsen 2 
calls  attention  to  the  existence  of  a  "  branch  of  consider- 
able size  which  arises  from  the  posterior  tibial  artery,  about 
one  and  a-half  to  two  inches  above  the  ankle-joint,  and 

'It  is  now  generally  considered  better  to  divide  the  tendon  from 
above  downward,  after  disarticulating,  keeping  the  edge  of  the  knife 
close  to  the  upper  and  posterior  aspect  of  the  bone. 

-'Science  and  Art  of  Surgery,  Vol.  I.,  p.  77.      Lea,  Phila.,  1873. 


100  AMPUTATIONS. 

passes  down  to  the  inner  side  of  the  us  calcis,"  communi- 
cating freely  above,  below,  and  behind  this  hone  with  the 
peroneal  artery  on  the  other  side.  As  these  anastomosing 
loops  lie  much  nearer  the  hone  than  the  skin,  great  num- 
bers of  them  will  be  divided,  and  the  vitality  of  the  flap 
endangered,  unless  the  edge  of  the  knife  is  kept  close 
against  the  hone  during  the  dissection.  Lister  goes  so  far 
as  to  say  that  sloughing  of  the  flap  is  always  the  fault  of 
the  surgeon,  and  Bell  intimates  the  same  thing. 

Rous  '  has  shown  that  this  elose  dissection  is  not  with- 
out its  dangers  from  the  other  side.  In  two  of  his  cases 
osteophytes  developed  within  the  stump  from  portions  of 
the  periosteum  left  adherent  to  the  flap.  The  autopsy  in 
one  of  these  cases  showed  that  six  osteophytes  had  formed 
and  become  carious  within  a  year  after  the  operation. 

A  short  longitudinal  incision  through  the  deep  parts 
along  the  middle  of  the  plantar  aspect  of  the  ealcaneum 
will  sometimes  render  this  step  of  the  operation  easier  and 
be  less  disadvantageous  than  the  employment  of  great  force. 

Modifications.  A.  Internal  Lateral  Flap. — When 
the  (.liter  side  of  the  foot  has  been  so  altered  by  injury  or 
disease  that  the  heel  flap  cannot  be  obtained,  a  very  good 
substitute  may  he  had  in  the  large  internal  flap  suggested 
by  Jules  Rous  and  adopted  with  Blight  changes  by  Sedil- 
lot,  Mackenzie,  and  others.  Spenee  says  this  stump  can 
hardly  he  distinguished  from  Syme's. 

An  incision  (Fig.  38)  is  commenced  at  the  outer  side 
of  the  tendo  Aehillis,  a  little  above  its  insertion,  carried 
straight  forward  under  the  outer  malleolus,  then  in  ;i 
curved  line  across  the  instep  half  an  inch  in  front  of  the 
anterior  articular  edge  of  the  tibia  and  backward  to  a 
point  just  in  front  of  the  inner  malleolus;   thence  directly 

downward  to  the  sole,  across  it  obliquely  backward  to  its 

outer  border  and  then    backward  and    upward  around    the 

heel  t"  the  point  al  which  it  began.  The  edges  of  the 
flaps  are  aexl  dissected  up  for  a  shorl  distance,  the  joint 
entered  at  the  outer  side  and  the  internal  flap  completed 
from  within  outward  after  disarticulation. 

1  Hull.  .1.-  I:,  Hoc.  'I-  Chirurgie,  Tom.  III.,  p.  191,  L853. 


AMPUTATION  AT  TEE  ANKLE-JOlMT  101 

Sedillot's  modification  of  this  consists  in  making  the 
flap  more  quadrilateral  than  triangular,  by  a  semicircular 
incision  across  the  dorsum  three  finger-breadths  in  front 
of  the  malleoli  and  by  carrying  the  posterior  end  of  the 
external  horizontal  incision  across  the  tendo  Achillis  to 
its  inner  border. 

Mackenzie's  method  differs  only  in  beginning  the  in- 
cision at  the  inner  border  of  the  tendon  and  a  little 
higher  up. 

It  is  probable  that  a  serviceable  external  flap  could  be 

Fig.  38. 


Amputation  through  the  ankle-joint  by  large  internal  lateral  Hap.     (Roux.) 

made  in  the  same  way,  although  its  vascular  supply  would 
be  scantier. 

B.  Pirogoff's  Amputation. — This  is  a  much  more 
important  modification,  since  it  involves  not  merely  the 
method  of  performing  the  operation,  but  also  the  reten- 
tion of  the  posterior  portion  of  the  calcanenm,  and  its 
ultimate  union  with  the  tibia.  The  only  additional  ana- 
tomical point  that  needs  mention  in  connection  with  it  is 
that  the  long  axis  of  the  calcanenm  is  directed  upward  as 
well  as  forward. 

An  incision  (Figs.  39  and  40,  A)  is  made  from  the  tip 
of  the  inner  malleolus  to  a  point  a  little  above  and  in 
front  of  the  tip  of  the  onter  malleolus,  crossing  the  instep 


102 


iMPUTATIONS. 


half  an  inch  in  front  of  the  anterior  edge  of  the  tibia.  A 
second  incision  crossing  the  sole  at  the  level  of  the  calca- 
ueo-cuboid  articulation  unites  the  extremities  of  the  first, 

Fig.  39. 


Piroeoff's  amputation.    A.  Cutaneous  incision  (outer  side).    B.  Line  of  section 
of  the  Dones. 

Fig.  40. 


>ff 'b  amputation.    A.  Cutaneous  Incision  (inner  Bide),    B.  Parallel  section 
..i  the  bones  [Bt  dillot's  modification  I. 


and  should  be  carried  boldly  down  to  the  bone.  The 
plantar  Bap  ia  then  dissected  l»;iel<  for  a  quarter  of  an  inch, 
and  the  dorsal  flap  to  the  edge  of  the  joint,  the  malleoli 


AMPUTATION  AT  THE  ANKLE-JOINT.  103 

well  exposed,  and  the  joint  opened  widely  by  dividing 
the  lateral  ligaments.  By  drawing  the  foot  forward  and 
depressing  it  a  narrow  saw  or  Gigli  wire  can  be  passed 
through  the  joint,  and  applied  to  the  ealcaneura  behind 
the  posterior  lip  of  the  astragalus,  and  the  bone  sawn 
through  downward  and  forward  in  such  a  direction  that 
the  section  will  terminate  half  an  inch  behind  the  lower 
edge  of  the  calcaneo-cuboid  articulation.  The  malleoli 
and  a  slice  of  the  tibia  are  then  removed  as  in  Syme's 
operation,  and  enough  of  the  anterior  angle  of  the  calca- 
neus removed  to  make  the  length  of  its  surface  of  section 
correspond  with  that  of  the  tibia.  Some  surgeons  prefer 
to  reverse  this  order,  and  remove  the  malleoli  before  saw- 
ing through  the  calcaneum. x 

The  cut  surface  of  the  calcaneum  must  then  be  brought 
up  against  that  of  the  tibia,  and  if  the  section  of  the  former 
has  been  sufficiently  oblique,  and  has  commenced  far 
enough  back,  this  can  be  done  without  making  excessive 
tension  upon  the  tendo  Achillis,  otherwise  another  slice 
must  be  removed  from  one  of  the  bones  or  the  tendon  di- 
vided subcutaneousl  v.  Suturing  together  of  the  bones  has 
been  occasionally  tried,  as  has  also  fastening  them  to- 
gether by  a  long  steel  pin  driven  through  the  sole  and  the 
calcaneum  into  the  tibia. 

Several  modifications  of  this  operation  have  been  sug- 
gested, but  they  can  hardly  be  considered  as  improve- 
ments. Vertical  division  of  the  calcaneum,  as  originally 
proposed  by  Pirogoff  and  Ure,2  deprives  the  stump  of  the 
advantages  of  the  heel  pad  by  swinging  the  latter  too  far 
forward,  and  bringing  the  weight  of  the  body  upon  the 
thinner  skin  covering  the  insertion  of  the  tendo  Achillis. 
It  also  causes  undue  tension  of  the  tendon  when  the  bones 
are  brought  together.  Sedillot  suggested  an  oblique  sec- 
tion of  the  tibia  upward  and  backward,  parallel  to  that  of 

1  Pirogoff' s  incisions  were  nearly  identical  with  Syme's.  He  also 
divided  the  calcaneum  vertically,  and  retained  the  articular  surface  of 
the  tibia  unless  it  was  diseased. 

2Ure's  conception  of  the  operation  seems  to  have  been  original  witli 
him.  His  case  was  published  in  the  Lancet  about  the  time  of  the  ap- 
pearance of  PirogofTs  book  at  Leipzig,  1854. 


H>4  AMPUTATIONS. 

the  calcaneum  (Fig.  40,  B).     This  avoids  any  stretching 

of  the  tendon,  and  insures  a  well-placed  pad  under  the 
heel,  but  it  shortens  the  limb  somewhat,  and  places  the 
point  of  support  behind  the  axis  of  the  leg.  Pasquier 
saws  both  tibia  and  calcaneum  horizontally  ;  this  is  diffi- 
eult  of'  execution,  endangers  the  Hap,  and  also  leaves  the 
point  of  the  heel  too  far  back.  The  suggestion  which  is 
occasionally  made  to  retain  the  malleoli  is  unsurgical  and 
unprofitable — unsurgical,  because  union  between  two  cut 
surfaces  of  cancellous  bone  is  speedier,  stronger,  and  not 
exposed  to  greater  risks  than  when  one  surface  is  covered 
with  articular  cartilage  ;  unprofitable,  because  nothing  is 
gained  in  accuracy  of  adjustment  or  length  of  limb. 

Comparison  of  the  Different  Methods  of  Par- 
riAL  and  Total  Amputation  ok  the  Foot. — As  an 
offset  to  the  advantage  of  their  less  extensive  mutilation, 
Lisfranc's  and  Chopart's  amputations  are  open  to  the  ob- 
jection that  the  unopposed  action  of  the  muscles  of  the 
calf  may  raise  the  heel  permanently  and  bring  the  weight 
of  the  body  upon  the  end  of  the  stump  and  the  cicatrix, 
and,  furthermore,  when  these  amputations  have  been  per- 
formed for  disease  of  the  bones,  those  bones  which  were 
left  behind,  even  if  apparently  healthy  at  the  time  of  the 
operation,  have  ultimately  become  affected. 

Byrne's  amputation  gives  an  excellent  stump  and  the 
shortening  of  the  limb  is  no  more  than  is  necessary  to 
permit  the  adaptation  of  an  artificial  foot  and  a  spring 
under  the  heel,  but  it  is  comparatively  difficult  of  execu- 
tion and  the  flap  is  liable  to  pouch  and  favor  infection. 
PirogofPs  method  is  easier  of  execution  and  gives  a  longer 

limb,  but  an  artificial  foot  cannot  lie  fitted  to  it  so  advan- 
tageously :    it    brings    the   heel   pad  a  little  too  far  forward 

and  requires  a  longer  time  for  recovery  from  the  opera- 
tion. The  subastragaloid  disarticulation  gives  a  longer 
limb  and  a  -j'""!  stump,  which  share-  with  Chopart's  the 
advantages  accruing  from  preservation  of  the  ankle  joint. 
(See  also  Mikulicz's  osteoplastic  excision  of  the  heel.) 


AMJTTATIOS    OF  THE   LEG.  105 

AMPUTATION  OF   THE  LEG. 

. I.  Lower  Third. — This  may  be  done  by  the  pure  or 
modified  circular,  or  with  a  long  anterior  flap  made  to 
overhang  the  square-cut  posterior  segment  of  the  limb,  or 
with  a  long  elliptic  posterior  flap,  including  the  whole  of 
the  tendo  Achillis.  The  former  results  in  a  central  adher- 
ent cicatrix  ;  in  all  the  coverings  are  liable  to  be  thin  and 
tender  and  the  artificial  limb  must  be  so  adjusted  that  the 
weight  will  be  received  by  the  sides  of  the  leg  and  not 
upon  the  face  of  the  stump.  The  compensatory  advan- 
tages are  that  the  control  of  the  limb  is  more  perfect  than 
with  a  shorter  stump. 

1.  Circular  Method. — A  circular  incision  is  made 
through  the  skin,  and  a  cutaneous  sleeve  one  inch  long 
behind,  two  inches  in  front,  is  dissected  up  ;  the  soft  parts 
are  cut  straight  through  to  the  bone  at  the  base,  and  then 
retracted  with  a  two  or  three-tailed  band,  according  to  the 
breadth  of  the  interosseous  membrane,  and  the  bones  sawn 
through,  beginning  and  ending  with  the  tibia. 

Bruns's  Method.1 — While  the  skin  is  strongly  drawn 
up,  a  circular  incision  is  made  down  to  the  bone  at  a  dis- 
tance below  the  future  saw-line  equal  to  two-thirds  of  the 
diameter  of  the  leg  at  the  saw-line.  Liberating  incisions 
about  two  inches  long  are  carried  upward  from  the  circular 
incision,  dividing  all  the  soft  parts  over  the  inner  border 
of  the  tibia  and  the  outer  aspect  of  the  fibula.  Without 
disturbing  the  attachments  of  the  overlying  soft  parts,  the 
periosteum  is  carefully  raised  from  the  tibia  and  fibula  as 
high  as  the  lateral  liberating  incisions  extend,  and  first  the 
fibula  and  then  the  tibia  are  sawn  through,  the  latter  ob- 
liquely to  prevent  projection  of  the  crest.  The  vessels  are 
then  ligated,  the  extremities  of  the  tendons  excised,  and 
buried  sutures  passed,  uniting  the  muscles  and  periosteum, 
and,  after  rounding  off  the  corners,  the  wound  is  closed 
with  a  drain  in  the  upper  angle  of  the  lateral  incisions. 

In  the  upper  half  of  the  leg  the  circular  incision  is  made 
first  through  the  skin,  and  then  the  muscles  are  divided  a 
finger's  breadth  higher  up.     This  preservation  of  the  peri- 

^eitrage  zur  klin.  Chip.,  1893,  p.  492. 


106 


AMPUTATIONS. 


osteum   is  to  be  deprecated  in  the  young  for  the  reasons 

given  in  the  toot  note  on  page  72. 

2.  Modified  Circular.  (Fig.  41,  A.) — Circular  in- 
cision through  the  skin,  met  by  a  liberating  longitudinal 
one  on  the  antero-external  aspect.     The  soft  parts  of  the 


Fig.  41. 


Fig.  42. 


11      Imputation  of  leg.   A.  Modified  circular.   /;.  Rectangular  flaps  (Teale). 

■■  ro-posterior  flaps,  upper  third  (  Ui.i.i  ). 

-Amputation  of  leg.      i.  Long  anterior  flap.    B.  Bupra-malleolar  ampu- 
tation i>y  long  posterior  flan  (Guyoh).    0.   A.1  the  upper  third  [St ox),     D 

skin  flap's  and  circular  division  <>f  the  muscles, 


AMPUTATION  OF  THE   LEG.  107 

posterior  portion  are  divided  rather  lower  than  those  of 
the  anterior  portion,  and  all  are  dissected  back  to  the  line 
at  which  the  bones  are  to  be  divided. 

Instead  of  a  single  liberating:  incision  two  may  be  made, 
one  on  each  side;  and  then  by  rounding  off  the  corners  we 
may  have  double  skin  flaps  with  circular  division  of  the 
muscles,  the  "  modified  flap  "  operation. 

3.  Long  Anterior  Flap  (Bell).  (Fig.  42,  A.) — An 
anterior  flap,  equal  in  length  to  the  diameter  of  the  leg  at 
its  base,  is  marked  out  by  a  curved  incision  through  the 
skin,  beginning  at  the  posterior  edge  of  the  tibia  on  the 
inner  side,  a  little  below  the  point  at  which  the  bones  are 
to  be  divided,  and  ending  at  a  point  directly  opposite  over 
the  fibula.  The  anterior  muscles  are  divided  transversely 
half  an  inch  above  the  lower  end  of  the  flap,  and  carefully 
dissected  off  the  bones  and  interosseous  membrane  as  high 
as  the  base  of  the  flap.  The  separation  from  the  interos- 
seous membrane  should  be  made  with  the  finger  or  handle 
of  the  knife,  in  order  that  the  anterior  tibial  artery  which 
lies  immediately  upon  the  membrane  may  not  be  injured. 
The  posterior  flap  is  then  made  by  transfixion  and  cutting 
transversely  outward,  and,  the  soft  parts  being  retracted, 
the  bones  are  sawn  across  a  little  higher  up. 

The  resulting  cicatrix  is  posterior  and  not  adherent  to 
the  end  of  the  bone.  Bell l  reports  five  cases,  in  all  of 
which  there  was  complete  and  rapid  recovery,  with  a 
useful  stump. 

4.  Elliptic  Posterior  Flap  (Guyon  2 ).  (Figs.  42 
and  43,  £.) — The  incision  is  made  in  the  form  of  an 
ellipse,  whose  lower  end  crosses  the  heel  below  the  inser- 
tion of  the  tendo  Achillis,  and  whose  upper  end  is  about 
an  inch  above  the  anterior  articular  edge  of  the  tibia. 
Beginning  at  the  lower  end  and  dividing  the  tendo 
Achillis  at  its  insertion,  and  hugging  the  bone  all  the  way, 
the  flap  is  dissected  up  posteriorly  as  high  as  the  upper 
end  of  the  ellipse.  The  anterior  muscles  are  then  divided 
by  transfixion,  the  bones  sawn  through,  and  the  posterior 
tibial  nerve  resected. 

1  Manual  of  Surg.  Operations,  3d  ed.,  p.  85.    Edinburgh,  1874. 
2 Bulletin  de  la  Soci^te"  de  Chirurgie,  1868,  p.  337. 


108 


MPVTATIONS. 


In  thi-  operation  the  sheath  of  the  tendo  Achillis  is  not 
opened,  and  the  tendon  itself  serves  afterward  as  a  cover- 
ing for  the  end  of  the  bone. 
Fig.  43.  B.    Middle  Third. — 1.  Long  an- 

terior curved  flap.  2.  Simple  pos- 
terior flap.  3.  Skin  flap  and  circu- 
lar division  of  the  muscles. 

1.  The  Long  Anterior  Curved 
Flap  is  made  according  to  the  meth- 
od described  for  its  use  in  the  lower 
third.  The  principal  points  to  be 
borne  in  mind  are  to  separate  the 
anterior  muscles  from  the  interos- 
seous membrane  with  the  finger  or 
handle  of  the  knife,  to  make  the  flap 
long  enough  to  fall  over  and  cover 
the  broad  posterior  surface  of  section 
without  tension,  and  to  saw  off  ob- 
liquely the  prominent  angle  made 
by  the  crest  of  the  tibia. 

2.  SlNGLE   POSTERIOE    FLAP. 

"When  the  muscles  have  become 
atrophied  a  single  posterior  Hap  may 
lie  safely  made.  A  transverse  inci- 
sion is  made  across  the  front  of  the 
leg  from  the  posterior  edge  of  one 
bone  to  that  of  the  other,  and  a  long 
posterior  flap  cut  from  within  out- 
ward, by  transfixion.  Its  length 
should  l)i'  equal  to  the  diameter  of 
the  leg  at  its  base. 

:}.  Skin   Flaps  and  (  Jirculae 

Amputation  of  the  leg  and     Division  OF  THE  MUSCLES.      (Fig. 
at   tbe  knee.     A.    Long  \»<^-  .         ,  ... 

ectanaular  flap  (Lee).      p>    /).) — Longitudinal   incisions  are 

/.•    -.i|.i   i  -  m;ill.  •■;  °  . 

C  At  the  upper  third  (Sedil-    made  on  t  lie  anterior   and    posterior 

ii  illation   :it  ,.   ,  i       i  •!  i 

(he  knei     oval  Incision,  aspects  ol    the    leg,  midway   hetween 

the  tibia  and  fibula.     They  should 

extend   downward    from  a   point    about    an  inch    below  the 
future  Baw-line  to  a  point  at  a  distance  from  the  saw-line 


AMPUTATION  OF  THE  LEO.  109 

equal  to  two-thirds  of  the  diameter  of  the  leg  where  the 
hone  is  to  be  divided.  These  are  joined  by  transverse  in- 
cisions with  the  corners  slightly  rounded.  The  incisions 
are  carried  through  the  skin  and  subcutaneous  tissue,  and 
the  flaps  thus  formed  are  turned  back,  drawn  up,  and  dis- 
sected from  the  fascia,  with  care  to  include  all  the  subcu- 
taneous cellular  tissue,  till  the  point  of  bone  division  is 
nearly  reached. 

The  muscles  are  then  cut  transversely  to  and  between 
the  bones,  the  interosseous  membrane  divided,  a  three- 
tailed  retractor  applied,  and,  after  circular  division  of  the 
periosteum,  the  bones  are  sawn,  finishing  with  the  fibula 
first.  The  cicatrix  will  lie  between  the  tibia  and  fibula. 
This  is  generally  the  best  method  for  amputation  of  the  leg. 

C.  Upper  Third.  ("Place  of  Election." )— The  bones 
should  never  be  divided  above  the  attachment  of  the  liga- 
mcntum  patellae  to  the  tuberosity  of  the  tibia,  and  it  is 
better  to  divide  two  inches  below  it,  when  possible,  so  as 
not  to  open  the  sheaths  of  the  flexor  muscles  of  the  thigh. 
The  circular  and  the  various  flap  methods  may  be  em- 
ployed. 

4.  Long  Anterior  Rectangular  Flap  (Teale).1 
(Fig.  41,  B.) — This  and  the  following  method  have  been 
practically  abandoned  on  account  of  the  great  sacrifice  of 
sound  parts  which  they  entail.  From  each  end  of  the 
transverse  diameter  of  the  leg  at  the  point  at  which  the 
bones  are  to  be  divided  an  incision,  equal  in  length  to  half 
the  circumference  of  the  leg  at  that  point,  is  made  down- 
ward and  slightly  backward,  so  that  the  two  shall  be  as 
far  apart  as  they  are  at  their  upper  ends,  measuring  across 
the  front  of  the  leg.  Their  lower  extremities  are  then 
united  by  a  transverse  anterior  incision  carried  through 
to  the  bones  and  interosseous  membrane.  The  flap  thus 
marked  out  is  dissected  up  to  its  base,  the  separation  from 
the  interosseous  membrane  being  made  with  the  finger  or 
handle  of  the  knife  so  as  not  to  injure  the  anterior  tibial 
artery. 

A  posterior  flap,  one-fourth  the  length  of  the  anterior 
1  See  also  page  74. 


110  AMPUTATIONS. 

one,  i>  next  cut  by  a  transverse  incision  straight  down  to 
the  bones,  and  disserted  back  to  the  same  point,  the  inter- 
osseous membrane  divided,  the  bones  cleaned  and  sawn 
through. 

The  long-  flap  is  then  doubled  back  upon  itself,  its  lower 
end  sewed  to  that  of  the  posterior  flap,  and  the  edges  of 
the  lateral  incisions  fastened  together. 

5.  Long  Posterior  Rect angular  Flap  (Lee).  (Fig. 
13,  A.) — The  incisions  are  similar  to  those  used  in  Teale's 
method,  but  they  involve  only  the  skin,  and  the  short  flap 
is  anterior,  the  long  one  posterior.  The  posterior  flap 
contains  only  the  gastrocnemius  and  soleus,  while  the 
deeper  layer  of  muscles,  together  with  the  large  vessels 
and  nerves,  is  cut  transversely  as  high  as  the  lateral  in- 
cisions permit. 

1.  Modified  Flap  (Bell).  (Fig.  41,  (J.)— Two  equal 
semi-lunar  flaps  of  skin  three  inches  long,  one  antero- 
external,  the  other  postcro-internal,  their  extremities  meet- 
ing at  opposite  points  about  two  inches  below  the  tuber- 
osity of  the  tibia.  These  must  be  reflected  up,  and  with 
them  another  inch  of  skin,  embracing  the  whole  circum- 
ference of  the  limb,  must  be  dissected  up.  The  anterior 
muscles  must  be  cut  as  high  as  exposed,  and  the  posterior 
ones  about  the  middle  of  their  exposed  surface.  The 
bones  must  then  be  sawn  as  high  as  exposed,  the  fibula 
being  finished  first,  and  the  sharp  prominence  of  the  edge 
of  the  tibia  removed. 


COMPARISON  OF  THE   DIFFERENT  METHODS. 

Amputation  in  the  lower  third  gives  better  command  of 
tlif  limb,  but  the  coverings  of  the  stump  arc  liable  to  be 
too  thin  ami  tender.  The  circular  and  double  flap  meth- 
ods formerly  gave  central  cicatrices  and  stumps  that  would 
bear  no  weight  upon  their  face,  and  were  sometimes  so 
sensitive  that  even  the  pressure  of  a  stocking  could  hardly 
lie  borne.  Guyon's  long  posterior  flap  taken  from  the  heel 
promises  well  ;  in  the  first  case  reported  the  cicatrix,  six 

Weeks  after  the  operation,  was  two  inches  above  the  end  of 


AMPUTATION  AT  THE   KNEE.  Ill 

the  stump,  upon  which  forcible  pressure  could  be  made 
without  causing  any  pain.' 

The  long  anterior  flap  also  yields  a  cicatrix  which  is 
placed  posteriorly  and  out  of  the  way  of  pressure,  and  in 
short  it  may  be  said  that  the  reasons  which  made  the  upper 
third  the  place  of  election  have  lost  their  force  since  ampu- 
tation by  a  long  single  flap  has  been  shown  to  be  practi- 
cable at  any  point,  and  since  asepsis  during  healing  has 
improved  the  character  of  cicatrices. 

After  amputation  in  the  upper  third  the  weight  of  the 
body  may  be  borne  upon  the  tough  skin  below  the  patella, 
the  patient  kneeling  upon  his  artificial  leg  ;  or  the  stump 
may  fit  into  the  hollow  end  of  an  artificial  limb,  the  upper 
edge  of  which  will  receive  the  weight  from  the  lower  edge 
of  the  patella  and  the  broader  bony  surfaces  near  the  joint. 
In  either  case  motion  at  the  joint  is  preserved,  and  there 
is  no  pressure  upon  the  cicatrix. 

In  children  methods  of  amputating  which  retain  in  the 
flap  a  considerable  strip  of  the  periosteum  of  the  removed 
bone  should  be  avoided,  because  of  the  probability  of  an 
objectionable  formation  of  bone  by  it,  giving  the  stump  a 
shape  which,  because  of  an  erroneous  theory  of  its  pro- 
duction, has  been  termed  "physiological  conicity." 

AMPUTATION  AT  THE  KNEE. 

Under  this  head  are  ranged  pure  disarticulations  and 
amputations  through  the  condyles  of  the  femur.  In  dis- 
articulating, the  lateral  and  crucial  ligaments  should  be 
divided  near  their  attachments  to  the  femur,  and  the  semi- 
lunar cartilages  removed. 

A.  Disarticulation.  Long  Anterior  Flap.  (Fig.  44, 
A.) — A  tongue-shaped  flap  is  marked  out  by  an  incision 
beginning  half  an  inch  below  the  line  of  the  articulation 
nearly  as  far  back  as  the  posterior  border  of  the  condyle 
on  one  side,  and  ending  at  the  corresponding  point  on  the 

^n  a  letter  to  me,  dated  June,  1S77,  Prof.  Guyon  states  that  he  has 
amputated  four  times  by  this  method,  and  has  every  reason  to  he  satisfied 
with  the  result.  The  patients  bore  their  weight  upon  the  stump  as  freely 
as  upon  the  other  foot.  Two  cases  are  reported  in  the  Butt,  de  In  Sloe  de 
Chirurge,  1877,  p.  321.— L.  A.  S. 


112  AMPUTATIONS, 

other,  alter  crossing  the  leg  five  inches  below  the  patella. 
A  transverse  posterior  incision  unites  the  sides  of  the  first 
an  inch  below  its  ends.  The  flap  is  dissected  up  and  the 
disarticulation  completed  as  before. 

Lateral  Flaps  (Smith). — "Commence  an  incision 
about  an  inch  below  the  tubercle  of  the  tibia  and  cut  to 
the  bone  ;  carry  it  downward  and  forward  beyond  the 
curve  of  the  sides  of  the  leg,  thence  inward  and  backward 
to  the  middle  of  the  leg,  thence  upward  to  the  middle  of 
the  popliteal  space  ;  repeat  this  incision  upon  the  opposite 
side  ;  raise  the  flap  consisting  of  all  the  tissues  down  to 
the  bone  until  the  articulation  is  reached,  divide  the  lat- 
eral ligaments,  enter  the  joint  and  sever  its  connections 
internally  and  externally." 

I',.  Amputation  Through  the  Condyles.  Oval  Method. 
— An  oval  incision  crossing  the  front  of  the  leg  three  fin- 
ger-breadths below  the  end  of  the  patella  and  the  back 
three  finger-breadths  higher  than  in  front  is  made  through 
the  skin,  which  is  reflected,  and  the  joint  opened  above 
instead  of  below  the  patella,  which  is  not  included  in  the 
flap.  The  line  of  incision  is  similar  to  that  in  Fig.  4v>,  />, 
but  higher.  After  disarticulation  has  been  effected,  the 
posterior  soft  parts  divided  and  the  artery  tied,  the  con- 
dyle- are  -awn  through  above  the  edge  of  the  articular 
cartilage.  Or  the  saw  may  be  applied  without  having 
previously  disarticulated. 

Anterior  Flap  (Carden).1  (Fig.  -14,  B.) — "The  op- 
eration consists  in  reflecting  a  rounded  or  semi-oval  Hap 
of  -kin  and  fat  from  the  front  of  the  joint  ;  dividing 
everything  else  straight  down  to  the  bone  and  sawing  the 
bone  slightly  above  the  plane  of  the  muscles,  thus  form- 
ing a  flat-faced  stump  with  a  bonnet  of  integument  to  fall 
over  it. 

"The  operation  is  simple  and  is  performed  easily  in 
two  ways. 

"The  operator,  standing  on  the  right  > i < b •  of  the  Limb, 
seizes  it  between  his  left  forefinger  and  thumb  at  the 
spots  selected  for  the  base  of  the  flap  and  enters  the  point 
•  British  Med.  Journal,  April  16,  1864. 


AUPUTATIOX  AT  THE  KNEE. 


113 


Fig.  44. 


of  his  knife  close  to  his  finger,  bringing  it  round  through 
skin  and  fat  below  the  patella  to  the  spot  pressed  by  his 
thumb j  then  turning  the  edge  downward  at  a  right  angle 
with  the  line  of  the  limb,  he  passes 
it  through  to  the  spot  where  it  first 
entered,  cutting  outward  through 
everything  behind  the  bone.  The 
flap  is  then  reflected  and  the  re- 
mainder of  the  soft  parts  divided 
straight  down  to  the  bone;1  the 
muscles  are  then  slightly  cleared 
upward  and  the  saw  is  applied.  * 

"  Or  the  flap  may  be  reflected 
first  and  the  knee  examined,  par- 
ticularly if  the  operator  be  unde- 
cided between  resection  and  am- 
putation. In  amputating  through 
the  condyles,  the  patella  is  drawn 
down  by  flexing  the  knee  to  a 
right  angle  before  dividing  the 
soft  parts  in  front  of  the  bone  ;  or 
if  that  be  inconvenient  the  patella 
may  be  reflected  downward.   *    * 

"  The  flap  falls  easily  over  the 
end  of  the  bone,  and,  when  united 
to  the  posterior  integuments  by  a 
few  pins  and  sutures,  is  drawn 
strongly  upward  and  backward  by 
the  greatly  retracted  flexors,  and 
has  a  somewhat  puckered  and  re- 
dundant appearance  at  first. 

(I  ritti's  Modification. — 
This  is  the  analogue  of  Pirogoff's 
modification  of  Syme's  amputa- 
tion at  the  ankle.  The  articular  surface  of  the  patella  is 
removed  and  the  cut  surface  of  the  bone  applied  against 
that  of  the  femur.  The  natural  mobility  of  the  skin  over 
the  patella  is  preserved,  and  the  usefulness  of  the  stump  in- 

1  Lister  and  Bell  recommend  a  posterior  skin  flap  one  inch  long. 
8 


Amputation  at  the  knee  and 
lower  third  of  thigh.  A.  Disar- 
ticulation, long  anterior  Hap.  B. 
Amputation  through  the  condy- 
les (Caeden).  C.  Modified  Map 
amputation  at  the  lower  third  of 
the  thigh. 


114 


AMPUTATIONS. 


creased  thereby;  but  it  not  unfrequently  happens  that  the 
patella  is  drawn  upward  by  the  quadriceps  femoris,  and 
union  docs  not  take  place  between  the  two  bones.     Gritti 


Fig.  4o. 


i    Qritti's  amputation  at  the  knee ;  A'.  Lines  of  division  of  the  bone.    //.  Long 
anterior  flap  (8£dillot).    W .  Division  of  bone.      C.    Amputation  al    lower  third 
Division  of  the  bone.    D.  Disarticulation  at  the  hip. 

sawed  through  the  femur  al  the  upper  edge  of  the  articular 
surface,  but  I  have  alwaysfound  it  advisable  to  go  nearly 
an  inch  higher  in  order  to  prevent  tilting  of  the  patella. 
Von  Linharl  '  claims  that  the  stump  is  better  than  that 


AMPUTATION   OF   THE    THIGH.  115 

obtained  by  amputation  in  the  lower  third  of  the  femur, 
but  not  better  than  thai  obtained  by  disarticulation. 

A  rectangular  anterior  flap  (Fig.  45,  A)  extending 
from  the  center  of  the  condyles  to  the  tuberosity  of  the 
tibia  is  marked  out,  and  dissected  up  after  division  of  the 
ligamentum  patellae  as  near  as  possible  to  its  insertion  ; 
the  skin  covering  the  back  of  the  knee  is  divided  trans- 
versely, or  by  an  incision  curved  slightly  downward,  the 
anterior  Hap  turned  hack,  the  synovial  membrane  sepa- 
rated from  its  attachment  to  the  femur,  and  the  bone 
sawn  through  well  above  the  edge  of  the  articular  carti- 
lage. The  remaining  soft  parts  are  then  divided  from 
within  outward,  and  the  vessels  secured.  The  artic- 
ular surface  of  the  patella  is  then  sawn  off  and  its  cut 
surface  laid  against  that  of  the  femur  and  secured  by  two 
or  three  sutures  passed  through  the  periosteum. 

AMPUTATION  OF  THE  THIGH. 

The  central  position  of  the  femur,  and  the  abundance 
of  the  soft  parts,  have  made  it  possible  to  employ  a  great 
variety  of  methods  of  amputation,  but  the  superiority  of 
the  flap  operation  is  now  generally  admitted,  with  certain 
modifications  depending  upon  the  portion  of  the  limb  se- 
lected for  amputation.  Thus,  in  the  lower  third  when  the 
skin  over  the  patella  is  uninjured,  Garden's  method  is  to 
be  preferred  ;  when,  on  the  other  hand,  that  portion  of 
skin  is  unavailable,  the  long  anterior  flap  or  Syme's  mod- 
ified flap  operation  should  be  used  ;  and  in  order  to  com- 
pensate for  the  greater  retraction  of  the  posterior  muscles 
they  should  be  cut  obliquely  instead  of  transversely  in  the 
former  operation,  and  on  a  lower  level  than  the  anterior 
muscles  in  the  latter.  In  the  middle  third  the  long  an- 
terior flap  is  to  be  preferred.  Lateral  flaps  should  be 
avoided  on  account  of  the  tendency  of  the  bone  to  project 
at  the  anterior  angle. 

The  muscles  are  more  abundant  on  the  inner  and  pos- 
terior aspects,  and  this  disproportion  increases  toward  the 
hip.  The  femoral  artery  will  be  found  in  the  posterior 
'Compend.  v.  Operationslehre,  1867,  p.  401. 


116  AMPUTATIONS. 

flap  below  the  middle  of  the  thigh,  in  the  anterior  flap 
above;  care  must  be  taken  not  to  include  the  internal 
saphenous  nerve  in  the  ligature  placed  upon  it.  The  pro- 
funda artery  lies  close  behind  the  bone,  but  divides  early 
iuto  its  branches.  The  sciatic  nerve  lies  between  the  short 
head  of  the  biceps  and  the  adductor  magnus  j  it  should  be 
drawn  gently  downward  and  divided  again  high  up. 

Sometimes  the  band  of  the  tourniquet  prevents  the  mus- 
cles from  retracting  sufficiently  to  allow  the  bone  to  be 
cleared  to  the  proper  height.  Under  such  circumstances 
the  bone  should  be  divided  wherever  it  is  most  convenient, 
and  the  excess  sawn  off  after  the  vessels  have  been  tied. 

Garden's  Method  has  been  sufficiently  described. 
(See  p.  112.) 

Modified  Flap  Operation  in  the  Lower  Third 
( Svme).  (Fig.  44,  C.) — Two  equal  semilunar  flaps  of  skin 
and  fat,  one  anterior,  the  other  posterior,  are  made,  raised 
from  the  fascia,  and  retracted  two  inches  further  ;  "  the 
muscles  should  then  be  divided  right  down  to  the  bone,  on 
a  level  as  high  as  they  are  exposed  in  front,  as  low  as  they 
are  exposed  behind."  The  bone  i-  then  cleared  and  sawn 
through  two  inches  above  the  level  of  division  of  the  ante- 
rior muscles. 

Long  Anterior  Flap. — Se'dillot,'  writing  in  1854, 
says  he  has  used  this  method  exclusively  for  the  preceding 
seven  years.  Spence  J  describes  a  method  as  first  practised 
by  himself  in  1  858,  and  claims  that  his  "  flap  is  formed  on 
;i  principle  essentially  different  from  that  which  regulates 
the  construction  "  of  S&lillot's,  a  difference  which  is  not 

_  ni/able  in  the  descriptions,  the  length  of  the  flap    in 

each  case  being  equal  to  the  diameter  of  the  limb,  the 
breadth  of  its  base  "almosl  two-thirds  of  the  circumfer- 
ence "  according  to  Se'dillot,  "  fully  equal  to  one-half  the 

circumference"  according  to  Spence,  and  the  muscle  con- 
tained in  it  cut  obliquely  by  both,  so  that  it  shall  Dot  be 
too  thick.  Sedillot  divides  the  posterior  segment  of  the 
limb  transversely.     Spence  divides  it  obliquely  from  with- 

1  Me"decine  Op^ratoire,  2d  edition,  VoL  [.,  p.  466. 

'  Lectures  on  Surgery,  2d  edition,  VoL  I.,  p.  621,  Edinb.,  L876. 


AMPUTATION    OF  Till.    TIll'.ll  117 

out  inward  beginning  two  inches  below  the  base  of  the 
anterior  flap,  and  BOmetimes  takes  an  additional  inch  of 
skin,  a  difference  which  approximates  his  method  to 
Teak's.  Benjamin  Bell  also  describes  a  method  which  is 
nearly  identical,  and  O'Halloran  used  a  similar  one  in 
1  765,  but  his  flap  was  too  short  to  accomplish  its  purpose. 

Sedillot's  description  is  as  follows  (Fig.  45,  B): 

The  flesh  of  the  anterior  aspect  of  the  limb  is  grasped 
in  the  left  hand  and  an  incision  made  through  the  skin, 
marking  out  a  flap  whose  length  is  equal  to  one-third  and 
its  base  to  almost  two-thirds  of  the  circumference  of  the 
limb.  The  muscles  are  then  divided  obliquely  upward 
and  backward  so  that  the  flap  shall  not  be  too  thick,  the 
posterior  segment  of  the  limb  divided  transversely,  the 
bone  cleared  an  inch  or  two  higher  and  sawn  through. 
He  also  removes  the  anterior  edge  of  the  bone  obliquely. 
as  was  recommended  for  the  tibia. 

Spenoe  recommends  the  long  anterior  flap  as  especially 
applicable  to  amputation  in  the  lower  third,  and  he  make- 
it  as  low  as  possible,  so  that  its  lower  margin  is  on  a  level 
with  or  below  the  patella.  After  dissecting  up  the  skin 
to  the  upper  end  of  the  patella,  he  cuts  obliquely  upward 
through  the  anterior  muscles  to  the  bone  immediately 
above  the  condyles  (Fig.  4o,  C).  While  the  soft  parts 
are  retracted  and  after  the  bone  has  been  cleared  circu- 
larly, he  elevates  the  femur  so  as  to  project  it  fully  and 
divides  it  two  inches  above  the  base  of  the  flap. 

Modified  Circular  Amputation  en  the  Lower 
Third. — The  incision,  involving  only  the  skin,  is  begun 
at  the  outer  part  of  the  anterior  surface  of  the  thigh,  at  a 
distance  below  the  proposed  saw-line  equal  to  one-third  of 
the  diameter  of  the  limb  at  the  level  where  the  bone  is  to 
be  divided.  It  is  carried  obliquely  downward  across  the 
front  of  the  thigh  and  then  transversely  across  the  inner 
and  posterior  aspects  at  a  distance  below  the  proposed 
saw-line  equal  to  two-thirds  of  the  diameter  already  taken 
and  finally  upward  on  the  outer  aspect  to  the  point  at 
which  it  began.  The  skin  is  next  retracted  and  freed  all 
around  for  about  tM"o  inches. 


118  AMPUTATIONS. 

The  superficial  muscles  on  the  inner  and  posterior  as- 
pects of  the  thigh  are  divided  at  the  level  of  the  retracted 
skin  and  then  the  outer  and  deeper  muscles  are  severed 
< low  11  to  the  bone  at  the  highest  possible  level. 

In  cutting  the  muscles  the  obliquity  of  the  original 
incision  is  to  be  maintained.  Retractors  are  now  applied 
ami  the  bone  sawed,  taking  care  not  to  leave  a  projecting 
spike  at  the  linea  aspera. 

AMPUTATION  AT  THE  HIP- JOINT. 

The  affections  which  render  this  most  serious  operation 
necessary  are  often  of  such  a  nature  that  the  surgeon's 
choice  of  a  method  of  performing  it  is  greatly  restricted  ; 
he  must  take  his  flaps  where  he  can  get  them,  and  must 
regulate  his  incisions  by  existing  lesions.  Moreover,  the 
problem  is  not  to  obtain  a  flap  that  will  bear  pressure, 
but  to  remove  the  limb  in  the  manner  that  involves  the 
Leasl  risk  to  life.  This  risk,  which  has  proved  very  great, 
is  due  not  only  to  the  gravity  of  the  lesions  which  render 
surgical  interference  necessary,  but  also  to  three  causes 
which  originate  in  the  operation  itself.  These  are  loss  of 
blood,  shock,  and  septicemia.  The  first  two  are  the  prin- 
cipal dangers,  as  modern  methods  have  minimized  the 
chances  of  infection,  although  formerly  they  were  con- 
siderable 

The  opinion,  held  by  many,  that  the  amount  of  shock 
varied  directly  with  the  length  of  time  employed  in  re- 
moving the  limb,   led    to  the   introduction  of  operative 

methods  characterized  by  extreme  rapidity  of  execution, 
not  more  than  thirty  seconds  being  allowed  for  the  re- 
moval of  the  limb  from  the  body  ;  the  type  of  these  is 
the  method  by  a  long  anterior  flap  made  from  within  out- 
ward by  transfixion. 

To  prevent  hemorrhage  many  expedients  have  been 
employed:  the  same  rapidity  of  execution;  compres- 
sion of  the  femoral  artery  upon  the  pubis,  or  within  the 
flap    by    an     assistant,    who    passes     his     lingers    into    the 

wound  behind  the  knife;  compression  of  the  aorta ;  pre- 
liminary Ligature  of  the  femoral   artery  ;   ligature  of  each 


AMPUTATION  AT  THE  HIP-JOINT.  119 

vessel  when  encountered  in  the  wound ;  laparotomy  and 
digital  compression  or  ligation  (q.  v.)  of  the  common 
iliac ;  compression  by  an  elastic  tourniquet  applied  above 
steel  pins  thrust  through  the  thigh.  The  hemorrhage 
most  to  be  feared  is  that  from  the  numerous  vessels  of  the 
posterior  segment  of  the  thigh,  for,  while  the  femoral 
artery  can  usually  be  controlled  without  much  difficulty, 
there  is  no  way  of  preventing  the  flow  of  blood  from  the 
others  except  by  compression  of  the  aorta  or  common 
iliac  through  the  walls  of  the  abdomen,  or  of  the  internal 
iliac  through  the  rectum,  or  by  previously  securing  the 
common  iliac  either  extra-  or  intra-peritoneally.  The 
latter  device,  first  suggested  as  a  means  of  hemostasis 
during  operation  for  gluteal  aneurism,  has  been  employed 
in  one  or  two  amputations  with  success  ;  compression  of 
the  aorta,  although  effectual  and  entirely  harmless  in 
some  cases,  has  proved  dangerous  or  impracticable  in 
others1  by  exciting  peritonitis  or  interfering  with  res- 
piration. 

A  simple,  efficient,  and  probably  safe  method  is  one 
recently  devised  and  successfully  employed  by  Dr.  Mc- 
Burney  :  direct  compression  of  the  common  iliac  artery  by 
the  finger  introduced  through  an  incision  in  the  anterior 
abdominal  wall. 

Dr.  AVyeth  2  uses  two  steel  mattress-needles  which  are 
thrust  through  the  thigh  to  prevent  the  slipping  of  an 
elastic  tourniquet  fastened  above  them.  The  first  needle 
is  entered  one  and  a-half  inches  below  and  just  to  the 
inner  side  of  the  anterior  superior  spine  of  the  ilium.  It 
passes  externally  to  the  neck  of  the  femur,  and  comes  out 
just  behind  the  great  trochanter  about  half-way  between 
it  and  the  posterior  superior  iliac  spine.  The  second 
needle  is  entered  an  inch  below  the  level  of  the  groin  in- 
ternal  to  the  saphenous  opening,  and,  passing  through  the 
adductors,  emerges  about  one  and  a-half  inches  in  front 
of  the  tuber  ischii.     A  stout  rubber  tube  is  then  wound 

'See  Erskine  Mason,  "Two  Successful  Cases  of  Amputation  at  the 
Hip-joint,"  N.  Y.  Med.  Journ.,  Dec,  1876. 
2  Journal  Am.  Med.  Assoc,  Feb.  7,  1891. 


L20  AMPUTATIONS. 

tightly  enough  around  the  thigh  above  these  pins  to  occlude 

the  vessel-. 

Dr.  McBurney  has  also  used  in  two  eases,  and  appar- 
ently with  great  advantage,  intra-venous  injection  of  a 
large  quantity  of  normal  salt  solution  during  the  operation. 

The  position  of  the  joint  may  be  determined  by  that  of 
the  anterior  inferior  spine  of  the  ilium,  which  is  three- 
quarters  of  an  inch  above  its  upper  margin. 

Nearly  all  of  the  numerous  methods  for  performing 
amputation  at  the  hip-joint  may  be  considered  as  varia- 
tions to  a  greater  or  less  extent  from  the  operation  by 
Maps,  which  may  be  either  external  and  internal  or  ante- 
rior and  posterior,  and  by  the  anterior  and  the  external 
oval — sometimes  called  racket — incision.  Disarticulation 
by  external  and  internal  flaps  is  not  to  be  commended 
except  for  cases  in  which  sound  tissue  cannot  be  obtained 
elsewhere.  The  knife  is  entered  about  a  hand's  breadth 
vertically  below  the  anterior  superior  spine  of  the  ilium 
and  made  to  transfix  the  thigh  from  before  backward  just 
below  the  great  trochanter ;  it  is  then  carried  down  and 
out,  cutting  a  flap  four  or  five  inches  long.  The  muscles 
are  then  separated  from  the  great  trochanter,  and  after 
disarticulation  the  inner  flap  is  cut  of  a  similar  length. 
Hemorrhage  is  controlled  by  the  pressure  of  an  assistant's 
finger-  entered  in  the  track  of  the  knife  and  by  ligation  of 
each  vessel  as  soon  as  possible  after  it  is  divided. 

When  the  nature  of  the  disease  or  injury  permits,  the 
operation  by  the  external  racket  incision  is  generally  given 
the  preference.  In  this  the  bone  is  approached  through 
the  least  vascular  area,  and  the  incision  can  also  be  used 
Ibr  exploration  before  proceeding  to  amputation. 

1.  A.NTERIOB  Racket  ob  Oval  Method. — The 
patient   having  been  anaesthetized  and  placed    upon    the 

table,  an    Esmarch's  elastic  band  is  applied   from    the    toes 

a-  far  upward  as  isallowed  by  the  nature  of  the  lesion  and 

the  line  of  the  proposed  incision. 

I.  An  incision,  beginning  a  finger's  breadth  below  Pou- 
part'fi    ligament,  is  carried  down    along   the   course  of  the 

femoral  artery  for  about  four  inches  ;  thence  outward  and 


AMPUTATION  AT  THE  HIP  .JOINT.  L21 

downward,  a  little  below  the  base  of  the  great  trochanter 
to  the  gluteal  fold  ;  thence  transversely  along  this  fold  to 
the  inner  side  of  the  thigh,  and  thence  obliquely  upward 
five  full  finger-breadths  below  the  genito-crural  fold  to 
the  point  where  it  diverged  from  the  line  of  the  artery. 
The  incision  should  involve  only  the  skin  and  the  cellular 
tissue  ;  any  vessels  that  are  divided  should  be  immediately 
tied. 

2.  The  sheath  of  the  vessels  is  opened,  the  artery  iso- 
lated and  denuded,  and  its  point  of  bifurcation  determined. 
A  ligature  is  then  applied  methodically  to  the  vessel  above 
the  origin  of  the  profunda,  and  a  second  lower  down,  in- 
cluding both  branches  en  masse,  and  the  artery  divided 
between  them.  The  femoral  vein  is  also  carefully  de- 
nuded and  divided  between  two  ligatures  at  about  the 
same  level. 

3.  The  incision  is  carried  down  through  the  muscles, 
beginning  on  either  the  outer  or  inner  side,  as  is  most  con- 
venient ;  on  the  inner  side,  after  having  cut  through  the 
adductors  at  the  junction  of  their  fleshy  and  tendinous 
portions,  seek  and  tie  the  obturator  vessels,  divide  the 
pectineus  and  psoas  on  a  line  with  the  neck  of  the  femur, 
and  secure  all  the  bleeding  points.  On  the  outer  side, 
divide  the  sartorius  and  the  fascia  lata,  and  then  invert 
the  thigh  so  as  to  throw  the  great  trochanter  forward  and 
facilitate  the. division  of  the  muscles  attached  to  it. 

4.  Open  the  articulation  in  front  and  divide  the  poste- 
rior portion  of  the  capsule  as  close  as  possible  to  the  femur, 
together  with  the  remaining  tendons  that  are  inserted  in 
the  great  trochanter. 

5.  Division  of  the  posterior  segment  of  the  limb.  De- 
press the  thigh  beyond  the  border  of  the  table,  so  as  to 
make  the  wound  gape  widely,  and  divide  the  remainder  of 
the  adductors  and  the  muscles  attached  to  the  ischium 
with  gentle  strokes  of  the  knife,  tying  each  vessel  when  it 
is  recognized  or  divided.  It  is  well  also  to  resect  the  ex- 
tremity of  the  sciatic  nerve. 

II.  External  Racket  Incision  or  Modified  Oval 
Method.  (Fig.  45,  D.) — The  patient  is  laid  upon  his  side, 


122  AMPUTATIONS. 

his  hips  at  the  foot  of  the  table.  A  straight  incision  four 
inches  long  is  begun  one  inch  above  the  summit  of  the 
great  trochanter,  and  carried  along  its  posterior  border, 
and  a  circular  incision  is  then  carried  from  the  lower  end 
of  the  first  around  the  thigh,  passing  three  inches  below 
the  tuberosity  of  the  ischium.  These  incisions  should 
interest  the  skin  only,  their  borders  should  be  dissected 
up  for  about  an  inch,  and  the  muscles  of  the  outer  aspect 
divided  obliquely  upward  toward  the  joint.  In  front  this 
division  should  not  be  carried  beyond  the  outer  edge  of  the 
rectus  muscle,  but  posteriorly  it  should  be  as  extensive  as 
possible  and  close  to  the  bone. 

The  thigh  being  flexed  and  adducted,  the  capsule  is 
opened,  first  longitudinally  on  the  finger  as  a  guide,  then 
forward  and  backward  along  the  edge  of  the  cotyloid 
cavity,  the  head  of  the  femur  dislocated  backward  and 
outward,  the  knife  passed  around  it  and  brought  down 
along  the  inner  side  of  the  bone  nearly  to  the  level  of  the 
circular  incision,  and  then  made  to  cut  its  way  rapidly 
out  on  the  inner  side. 

Esmarch's  method  differs  slightly  from  this  last. 
Hemorrhage  is  controlled  by  digital  pressure  on  the 
femoral  in  the  groin.  Five  inches  below  the  top  of  the 
great  trochanter  divide  everything  circularly  down  to  the 
bone,  which  is  at  once  sawn  aero-.-.      The  vessels  are  then 

secured.  Next  the  stump  of  the  femur  is  steadied  and  the 
knife  entered  about  two  inches  above  the  tip  of  the  tro- 
chanter and  carried  down  along  its  outer  surface  till  it 
reaches  the  first  circular  incision.  The  bone  i-  \'v<hh\  from 
-oft  parts  by  an  elevator  entered  beneath  the  periosteum, 
aided  by  the  knife,  the  muscular  insertions  on  the  tro- 
chanters divided,  the  capsule  opened,  and  the  bone  re- 
moved. 

III.    A.NTERIOB    FLAP. — The    position    of    the    patient 

being  the  same,  and  the  thigh  slightly  flexed  and  abducted, 

the  point  of  a  long  amputating-knife  is  entered  midway 
between  the  anterior  superior  -pine  of  the  ilium    and    the 

top  of  the  greai  trochanter  and  passed  inward  and  hack- 
ward  to  ;i  point  one  inch  below  and  in  front  of  the  tuber- 


AMPUTATION  AT  THE  HIP-JOINT  123 

osity  of  the  ischium,  grazing  the  anterior  surface  of  the 
Deck  of  the  femur,  and  certainly  opening  the  capsule  of 
the  joint  if  its  edge  is  kept  turned  obliquely  toward  it. 
(The  direction  may  be  reversed  for  the  right  thigh,  the 
knife  being  entered  on  the  inner  side.) 

A  well-rounded  flap  ending  at  the  junction  of  the  upper 
and  middle  thirds  of  the  thigh  is  then  cut  with  rapid  saw- 
ing movements  of  the  knife,  and  reflected  upward.  The 
limb  is  forcibly  depressed,  and  if  the  eapsule  has  been  well 
divided  this  movement  will  throw  the  head  of  the  femur 
forward  out  of  the  socket ;  and  if  not,  a  single  cut  with 
the  knife  across  the  head  of  the  bone  will  free  it.  The  leg- 
is  then  rotated  inward  so  as  to  bring  the  trochanter  for- 
ward, the  surgeon  passes  the  knife  behind  the  head  of  the 
bone  and  cuts  a  short  posterior  flap  from  within  outward. 

Sexn's  Bloodless  Method.1 — Start  an  incision  on 
the  outer  surface  of  the  thigh  about  three  inches  above  the 
trochanter,  and  carry  it  vertically  downward  for  about 
eight  inches,  exposing  the  outer  surface  of  the  trochanter 
and  femur. 

Keeping  close  to  the  bone,  separate  the  muscular  at- 
tachments to  the  great  trochanter,  and,  while  the  thigh  is 
flexed,  adducted,  and  rotated  inward,  open  the  eapsule 
transversely  at  its  upper  posterior  aspect.  Sever  the  rest 
of  the  ligaments  by  backward  dislocation  of  the  head  of 
the  femur,  which  is  then  pushed  out  of  the  wound  and  the 
lesser  trochanter  and  shaft  freed  as  low  as  desired. 

A  sinus-forceps  carrying  a  Ling  stout  doubled  piece  of 
rubber  tubing  is  pushed  through  the  wound  behind  the 
femur  at  the  normal  level  of  the  lesser  trochanter,  emerg- 
ing through  a  small  counter  opening  on  the  inner  surface 
of  the  thigh,  where  the  tube  is  cut  in  two  ;  one-half  is  tied 
tightly  about  the  anterior  segment  of  the  limb,  the  other 
is  crossed  about  the  posterior  segment  and  its  ends 
brought  around  and  tied  in  front  above  the  anterior  piece 
of  tubing.  Starting  from  the  points  of  emergence  of  the 
tourniquet  a  long  anterior  and  a  short  posterior  flap  are 
raised,  consisting  of  all  the  tissues  down  to  the  muscles, 
'Chic.  Clin.  Rev.,  Feb..  1893,  p.  343. 


124  AMPUTATIONS. 

which  are  then  cut  circularly  in  the  form  of  a  cone  with 
its  ;i]K'.\  at  the  lower  limit  of  denudation  of  the  femur. 
The  thigh  is  thus  removed,  and  after  ligating  all  visible 
vessels  with  catgut  and  excising  about  an  inch  of  the  ex- 
posed sciatic  nerve  the  tourniquet  is  loosened  from  the 
posterior  flap  first  and  then  from  the  anterior. 


PART  IV. 

EXCISION   OF   JOINTS   AND  BONES. 


Excision  of  a  joint  may  be  (1)  complete  or  (2)  partial. 
In  the  former  case  the  articular  ends  of  all  the  bones  com- 
posing it  are  removed  ;  in  the  latter,  one  or  more  are  re- 
tained. Again,  partial  excision  may  consist  of  (1)  partial 
or  (2)  total  resection  of  the  articular  end  of  one  of  the 
members  of  the  joint.  The  former  is  often  unadvisable  ; 
the  latter,  to  which  Oilier  l  has  given  the  name  of  semi- 
articular  resection,  has  given  good  results  in  traumatic 
eases,  and  of  late  also,  under  antiseptic  treatment,  in  tuber- 
culous affections  when  the  disease  is  still  restricted  to  a 
portion  of  the  bone  and  capsule. 

Excision  of  a  bone  may  be  total  or  partial,  and,  in  the 
case  of  the  long  bones,  with  or  without  either  or  both  epi- 
physes. 

The  term  resection  is  often  employed  as  a  synonym  of 
excision.  In  the  narrower  sense  it  refers  to  the  removal 
of  a  portion  of  a  bone,  including,  however,  its  entire  thick- 
ness ;  thus,  a  joint  is  excised  by  the  resection  of  the  bones 
composing  it. 

Joints  are  excised  on  account  of  injury,  disease,  or  an- 
chylosis in  a  faulty  position  ;  and  with  the  object  of  obtain- 
ing a  movable  joint,  as  in  the  upper  extremity,  or  anchy- 
losis, as  at  the  knee  and  ankle.  The  operative  procedures 
may  vary  with  these  causes  and  these  objects.  Thus, 
when  anchylosis  is  sought  for,  the  division  of  the  muscles 
and  tendons  about  the  joint  is  of  no  special  moment  ;  but 
if  the  joint  is  to  be  reestablished,  the  muscles  which  con- 

■Congivs  Medieal  de  France,  4th  session,  1872,  p.  224,  and  Bull,  de 
la  Soc.  de  Chirurgie,  187o. 

125 


126  EXCISION  OF  JOINTS  AND  BONES. 

trol  its  movements  must  not  be  disabled.  In  any  rase  the 
main  blood  vessels  and  nerves  must  be  respected;  the  in- 
cisions, whenever  practicable,  should  be  parallel  to  the 
long  axis  of  the  limb  ;  and  when  it  is  necessary  to  divide 
a  tendon  or  muscle,  the  line  of  section  should  be  oblique 
rather  than  transverse,  so  as  to  favor  reunion. 

The  incisions  should  be  sufficiently  free  to  allow  the 
bone  to  be  thoroughly  inspected  with  a  view  to  the  re- 
moval of  all  the  diseased  portion.  It  is  better  to  make  a 
dean  division  with  the  saw  than  to  remove  the  bone 
piecemeal,  but  the  use  of  the  gouge  is  proper  for  the  re- 
moval of  small  circumscribed  areas  of  disease  found  upon 
the  surfaces  of  section,  and  even  very  extensively  in  the 
young,  as  a  substitute  for  a  formal  excision  in  order  not 
to  diminish  the  subsequent  growth  of  the  limb  by  the  de- 
struction  or  removal  of  the  epiphyseal  cartilage. 

The  synovial  membrane  in  traumatic  and  non-tubercu- 
lous suppurative  cases  does  not  require  special  attention  ; 
in  tuberculous  cases  and  when  much  thickened  it  should 
be  cut  or  scraped  away  so  as  to  remove  such  foci  of  infec- 
tion as  may  exist  within  its  walls  or  in  the  fungous  gran- 
ulation- on  its  surface.  When  anchylosis  is  sought  for, 
as  at  the  knee,  it  is  prudent  to  dissect  out  the  sac  entirely. 
If  any  portion  is  necessarily  left,  the  destruction  of  the 
foci  should  be  sought  by  thorough  scraping,  washing  with 
a  solution  of  chloride  of  zinc,  1  to  30  or  40,  or  of  corrosive 
sublimate,   1   to  1,000,  or  by  the  actual  cautery. 

The  propriety  of  retaining  the  periosteum  is  still  a 
subject  of  discussion,  and  one  in  which  the  decision  will 
probably  vary  with  the  articulation  and  the  circumstances 
of  the  case.  Certain  facts  have,  however,  been  already 
established,  [ts  retention  is  a  safeguard  against  injury  to 
neighboring  tissues  during  the  operation  ;  after  excision  of 
,i  bone  it  gives  firmness  t<»  the  cicatrix,  diminishes  the 
shortening  of  the  limb,  and  insures  the  proper  attachment 

of  tie-  muscles  ;   and  iii    the   case  of  an  articulation,  if  its 

relation-  with  the  capsule  arc  maintained  (  periosteo-cap- 
sular  excision),  it  favors  the  reproduction  of  the  joint  with 
articular   curtilage-   and    ligamentary  support.     On   the 


EXCISION  OF  JOINTS  AND  BOXES.  127 

other  hand,  the  reproduction  of  bone  is  not  always  desir- 
able, and  may  be  excessive  or  irregular,  unduly  limiting 
the  motions  of  the  joint,  or  even  causing  anchylosis  ;  and, 
finally,  the  bruising  received  by  the  periosteum  during  the 
operation  may  cause  it  to  slough,  or  the  reproduction  of 
bone  may  fail  entirely. 

Von  Langenbeck  l  has  shown  that  in  excision  of  the 
shoulder-joint  it  is  of  the  utmost  importance  to  preserve 
the  relations  of  the  periosteum,  the  capsule,  and  the  ten- 
dons of  the  capsular  muscles,  but  in  all  other  joints,  ex- 
cept perhaps  the  hip,  the  importance  is  not  so  great  or, 
at  least,  so  well  established.  Complete  restoration  of  the 
shoulder-joint  and  reestablishment  of  the  control  of  the 
muscles  over  it  have  never  been  accomplished  except  by 
the  subperiosteal  method.  The  periosteum  can  be  re- 
moved without  difficulty  except  when  it  is  actively  in- 
flamed ;  its  connection  with  the  bone  is  very  slight  in 
cases  of  chronic  osteitis  and  synovitis.  The  tendons,  on 
the  other  hand,  are  so  firmly  attached  to  the  bone  that 
the  elevator,  or  rugine,  is  sometimes  insufficient  to  re- 
move them  properly  and  the  knife  must  then  be  used,  its 
edge  being  kept  as  close  as  possible  to  the  bone.  Von 
Langenbeck  goes  so  far  as  to  say  that  the  success  of  a 
periosteo-capsular  excision  depends  in  great  part  upon  the 
proper  alternation  in  the  use  of  the  knife  and  elevator. 

Vogt  and  Koenig  strongly  recommend  that,  instead  of 
separating  the  tendons  and  ligaments  from  the  bone,  the 
latter  should  be  cut  through  with  a  chisel  so  as  to  leave  a 
shell  attached  to  the  soft  parts.  In  children,  where  the 
epiphyses  are  still  cartilaginous,  this  section  can  be  made 
with  the  knife. 

Excision  of  single  bones  may  be  required  on  ac- 
count  of  injury  or  disease.  The  latter  is  by  far  the  most 
common  cause,  and  its  most  common  examples  are  tuber- 
culosis of  the  small  spongy  bones  and  necrosis  of  the 
long  ones,  due  to  acute  osteomyelitis.  The  incisions 
should  be  made  from  the  side  where  the  coverings  of  the 
bone  are  fewest  and  of  least  importance  ;  the  periosteum 
1  Archiv  fur  klinische  Chirurgie,  Vol.  XVI. 


L28  EXCISION   OF  JOINTS  AND  BONES. 

should  be  left  behind  and  all  the  diseased  bone  should  be 
removed.  When  the  entire  shaft  of  the  bone  has  become 
necrotic,  it  must  be  divided  with  the  chain-saw  or  cutting- 
pliers  and  each  piece  pulled  or  cut  away  from  its  epiphysis. 

MAJOR    ARTICULATIONS. 

EXCISION  OF  THE  SHOULDER-JOINT. 

As  formerly  performed,  excision  of  the  shoulder-joint 
was  an  operation  the  results  of  which,  to  quote  Holmes,1 
were  ••  probably  inferior — certainly  not  superior — to  those 
of  natural  anchylosis."  If  anchylosis  did  not  follow,  the 
joint  was  loose,  under  slight  control,  and,  at  the  best, 
could  not  be  raised  above  the  horizontal  line.  Oilier2  and 
Yon  Langenbeck,3  however,  have  shown  that  the  periosteo- 
capsular  method  furnishes  a  much  larger  measure  of  suc- 
cess. In  a  case  operated  upon  by  the  former,  where  four 
inchesof  the  humerus  were  removed,  the  ultimate  shorten- 
ing was  only  half  an  inch,  and  the  motions  were  quite 
full  ;  and  the  latter  reports  several  cases  in  which  the  arm 
could  be  raised  to  the  vertical  line,  and  the  control  of  the 
limb  was  perfect.  In  all  of  Von  Langenbeck's  cases  the 
operation  was  undertaken  on   account  of  gunshot-injury. 

As  the  capsular  muscles  are  attached  to  the  greater  and 
lesser  tuberosities,  the  capsule  and  periosteum  must  be 
divided  between  these  two  bony  prominences — that  is,  in 
the  direction  of  and  near  to  the  tendon  of  the  long  head  of 

the  biceps.  An  anterior  incision  beginning  at  theacromio- 
coracoid  triangle  is  the  best  one  for  this  purpose,  and  has, 
moreover,  the  advantage  of  sparing  the  posterior  circum- 
flex artery  and  the  nerve.  The  cephalic  vein  lies  in  the 
groove  between  the  deltoid  and  pectoral  muscles,  and  is 
avoided  by  making  the  incision  incline  outward.  When 
the  -"ft  parts  are  much  thickened  and   consolidated,   this 

incision    need-  to  be  supplemented    by  a    short    transverse 

'IV.  ii-  Principles  and  Practice,  p.  929.     Lea,  Phila.,  l.sTfi. 
Traite*  de  la  Regeneration  des  On,  and  des  Resections  des  Grandes 
Articulations,  1867. 

\n-liiv  fur  kliniache  Cbirurgie,  1874,  Vol.  XVI. 


EXCISION  OF  THE  SHOULDER-JOINT. 


129 


one  (Fig.  4(),  B)  running  outward  from  its  upper  end 
parallel  to  and  just  below  the  edge  of  the  acromion, 
dividing  the  fibers  of  the  deltoid  transversely  in  its  course; 
sometimes  the  condition  of  the  parts  is    such,  and    the 


Fig.    16. 


Excision  of  the  shoulder.    (Olliek.)   A.  Regular  incision.     B.  Supplementary. 

sinuses  so  placed,  that  a  large  external  flap,  with  its  base 
directed  upward,  has  to  be  made  by  a  triangular  or  curved 
incision,  and  raised  up  so  as  freely  to  expose  the  outer 
aspect  of  the  head  of  the  humerus.  In  any  case  the  trunk 
of  the  posterior  circumflex  artery  should  be  spared. 

Operation  (Oilier).  (Fig.  46.) — The  arm  isnddncted  nnd 
riihiiuiJiuua'd.  The  point  of  the  knife  is  entered  at  the 
beak  of  the  eoracoid  process,  and  carried  four  inches  down- 
ward and  outward  in  the  general  direction  of  the  Abel's  of 
the  deltoid,  or  as  much  further  as  may  be  necessary.  The 
incision  thus  made  will  be  external  to  the  inner  border  of 
the  deltoid,  and  should  comprise  all  the  tissues  down  to 
the  bone. 

The  edges  of  the  wound  are  held  apart  with  retractors, 
and  the  capsule  and  periosteum  are  divided  along  the 
outer  edge  of  the  tendon  of  the  long;  head  of  the  biceps  and 
the  bicipital  groove  to  the  full  extent  of  the  external  in- 
cision. The  outer  edge  of  the  incision  is  raised,  and  the 
periosteum,  together  with  the  capsule  and  tendons  of  _ the 
9 


130  EXCISION  OF  JOINTS  AND  BONES. 

muscles  inserted  upon  the  greater  tuberosity,  is  carefully 
detached  with  the  elevator  and  kniib.  while  an  assistant 
rotates  the  arm  inward  to  increase  the  extent  of  and  facil- 
itate the  dissection. 

The  tendon  of  the  biceps  is  then  raised  from  its  groove 
and  hold  out  oT  the  way,  the  arm  rotated  outward,  and  the 
periosteum,  capsule,  and  tendon  of  the  subscapulars  dis- 
sected  off  in  the  same  way  on  the  inner  side. 

The  head  of  the  humerus  is  then  dislocated  forward,  the 
posterior  attachments  of  the  capsule  separated  with  the 
elevator  or  knife,  the  periosteum  peeled  off  the  posterior 
face  of  the  neck  and  shaft  of  the  humerus,  and  the  bone 
sawn  through  transversely. 

If  the  articular  surface  of  the  glenoid  cavity  is  affected, 
it  must  be  scraped  ;  if  the  bone  itself  is  diseased,  it  should 
be  gouged  out  until  healthy  bleeding  bone  is  reached,  or 
the  neck  may  be  cut  through  with  strong  cutting-pliers 
after  removal  of  its  periosteum. 

Von  Lanoexbeck's  Method  differs  slightly  from  the 

above.      He   begins   his   ippisinn    «t,  thp  nfltprjnr  border  pf 

the  acromion  just  outside  of  the  a^aamjc^ajdcjilax  junc- 
tion,  and  carries  it  directly  downward,  the  arm  being  so 
held  as  to  bring  the  outer  condyle  of  the  humerus  in 
front.  This  sacrifices  the  inner  fibers  of  the  deltoid  by 
severing  their  nerves.  He  carries  the  incision  through  the 
muscle  down  to  the  capsule  and  bone,  then  raises  with 
toothed  forceps  the  sheath  of  the  tcmlun  of  thftJ>i<ms 
which  presents  in  theTine  of  the  incision,  and  opens  it 
carefully  from  without  inward.  As  soon  as  the  shining 
tendon  ifi  Been  he  slits  the  sheath  throughout  the  entire 
length  of  the  incision,  opening  the  capsule  quite  up  to  the 

acromion,  and  exposing  the  articular  end  of  the  humerus 
with    the  tendon  lying  upon  if. 

He  then  raises  the  periosteum  on  the  inner  side,  until 
the  hsser  tuberosity  is  reached,  lays  aside  the  elevator,  and 
peels  oh"  the  tendon  of  the  Bubscapukris  with  l^rjjjc  and 
toothed  force] is,  taTmg~TlTTrgreatest  pains  to  maintain  its 
relation-  with  the  capsule  and  periosteum.  After  this  dis- 
Bection    has    been  carried    as   far  as    possible   on    the    inner 


EXCISION  OF  THE  ELBOW-JOINT.  131 

side,  he  lifts  the  tendon  of  the  biceps  from  its  sheath,  car- 
ries it  inward,  drops  it  into  the  joint,  and  denudes  the  bone 
on  the  outer  side  with  the  same  precautions,  using  the 
knife  instead  of  the  elevator  to  detach  the  capsule,  tendons, 
and  ligaments.     The  rest  of  the  operation  as  above. 

If  only  the  articular  head  of  the  bone  is  to  be  resected, 
near  the  upper  end  of  the  tuberosities,  there  is  no  perios- 
teum to  be  removed.  The  ligamentous  and  muscular  at- 
tachments are  approached  from  within  the  joint,  and  the 
bone  divided  with  the  wire  or  keyhole  saw,  without  rais- 
ing it  from  its  place. 

By  a  Transverse  Incision.  (Xelaton,  Perrin.) — A 
transverse  incision  three  and  a-half  or  four  inches  long  is 
made  parallel  to  and  half  an  inch  below  the  edge  of  the 
acromion,  beginning  in  front  between  it  and  the  coracoid 
process.  The  fibers  of  the  deltoid  are  divided  close  to  the 
acromion,  and  by  their  retraction  expose  the  capsule 
largely. 

The  capsule  is  divided  along  the  outer  edge  of  the  ten- 
don of  the  biceps,  and  then  transversely  in  the  direction 
of  the  external  wound  ;  the  bone  is  approached  and  denuded 
through  this  opening,  and  the  operation  completed  as 
before. 

The  vessels  and  nerves  are  well  protected  by  this  method, 
but  it  is  difficult  of  execution. 

EXCISION  OF  THE  ELBOW-JOINT. 
Partial  excision  of  the  elbow-joint  for  disease,  even 
when  the  portions  left  behind  are  entirely  healthy,  gives 
as  a  rule  less  satisfactory  results  than  complete  excision. 
The  humerus  should  be  sawn  through  at  or  just  above 
the  epicondyles,  the  ulna  at  the  base  of  the  coronoid  proc- 
ess and  the  radius  through  its  neck.  The  extent  of  the 
disease  may  make  it  necessary  to  surpass  these  limits,  but 
the  result  will  then  be  less  perfect  and  in  any  case  every 
effort  should  be  made  to  preserve  the  continuity  between 
the  periosteum  and  the  tendons  of  the  brachialis  anticus 
and  biceps  SO  as  to  provide  for  future  flexion  of  the  fore- 
arm.     An  exception  to  the  rule  of  total   excision   may  be 


L32  EXCISION  OF  JOINTS  AND  BONES. 

found  in  the  preservation  under  some  circumstances  of  all 
the  olecranon  except  its  articular  surface  ;  the  joint  thus 
obtained  is  firmer  and  active  extension  more  powerful. 

Reproduction  of  bone  takes  place  less  completely  at  the 
elbow-joint  than  at  any  other  of  the  major  articulations, 
and  consequently  the  greater  the  amount  removed  the 
greater  the  danger  of  the  formation  of  an  imperfect,  loose 
and  inefficient  joint,  even  when  the  subperiosteal  method 
has  been  thoroughly  carried  out.  Ordinarily  anchylosis  is 
to  be  preferred  to  a  very  loose  joint. 

In  cases  of  gunshot-injury  Von  Langenbcek  and  Oilier 
remove  as  little  as  possible,  making  a  partial  (semi-articu- 
lar) excision  when  either  the  humerus  or  the  bones  of  the 
forearm  alone  are  injured.  The  English  authors  think 
the  danger  in  eases  of  excision  for  disease  is  rather  of  re- 
moving too  little  than  too  much  and  recommend  that  the 
humerus  be  sawn  through  above  the  condyles. 

A.s  the  joint  is  covered  anteriorly  with  soft  parts, 
among  which  lie  nearly  all  the  principal  arteries  and 
aerves,  and  is  almost  subcutaneous  posteriorly,  it  must  be 
approached  from  the  latter  side  and  the  incisions  must  be 
made  with  especial  reference  to  the  safety  of  the  ulnar 
nerve,  where  it  runs  between  the  olecranon  and  the  epi- 
trochlea.  The  original  method,  and  the  one  used  almost 
exclusively  for  many  years,  was  the  H-mcision,  composed 
of  two  longitudinal  incisions  connected  midway  by  a  trans- 
verse one  crossing  the  tip  of  the  olecranon.  Tt  is  inferior 
in  its  results  to  later  methods  and  does  not  need  to  be 
described. 

The  later  methods  have  been  devised  with  the  view  of 
sparing  the  ulnar  nerve,  preserving  the  attachment  of  the 
triceps    and    the    continuity  of  the   lateral    ligaments  with 

the  periosteum,  and  facilitating  the  operation.     Although 

the  central  longitudinal  incision  has  been  extensively  used 

the  preference  seems  mow  to  We  due  to  methods  of  ap- 
proach from  the  radial  Bide,  such  a-  Ollier's,  Xelaton's, 
and    Hueter"-. 

Central  Longitudinal  [ncision.  (big.  17.  A.) 
i  Von  Langenbeck.) — Thefbrearm  being  slightly  flexed,  a 


EXCISIOA    "I     THE   ELBOW  JOINT. 


1 33 


longitudinal  incision  3|  inches  long  is  made  a  little  to  the 
inner  —  i <  1 « ■  of  the  median  line  of  the  triceps  and  ulna,  and 
carried  down  to  the  bone.  The  inner  edge  of  the  divided 
periosteum  is  raised  from  the  ulna,  the  corresponding  half 

of  the  tendon  of  the  triceps  detached  with  it,  and  the  dis- 
section continued  toward  the  internal  condyle,  the  knife 
being  kept  constantly  against  the  hone,  and  the  flexion  of 
the  arm  increased  as  the  dissection  advances.  As  the 
epitrochlea  is  approached  the  greatest 
care  is  needed  to  preserve  the  connec- 
tion between  the  periosteum,  the  mus- 
cular attachments,  and  the  internal 
lateral  ligament,  and  it  may  be  neces- 
sary to  prolong  the  first  incision  up- 
ward so  as  to  set  more  room. 

After  the  inner  half  of  the  joint  has 
thus  been  laid  open  and  the  epitrochlea 
bared,  the  soft  parts  are  replaced  and 
a  similar  dissection  made  upon  the 
outer   side  with  the  same  precautions. 

The  humerus  is  then  dislocated  back- 
ward through  the  wound  and  sawn 
through  at,  or  as  near  as  possible  to. 
the  epieondyles,  according  to  the  lesion. 
If  the  condition  of  the  soft  parts  does 
not  allow  of  this  projection  of  the  hu- 

,,  .  ill  ,     joint.      A.    Von   Langen- 

merns,  the  wire  or  keyhole  saw  must  beck.    /;.  oilier, 
be  used. 

The  ulna  is  then  cleaned  circularly  as  far  as  necessary 
and  -awn  through,  and  the  head  of  the  radius  removed 
with  the  saw  or  cutting-pliers. 

Olliek's  Method.1  (Fig.  47,  B.) — The  forearm  is 
slightly  flexed,  and  an  incision  is  commenced  two  inches 
above  the  tip  of  the  olecranon  on  the  outer  side  of  the  arm 
at  the  interstice  between  the  triceps  and  supinator  longus. 
This  incision,  involving  the  skin  only,  is  carried  down- 
ward to  the  epicondyle,  thence  downward  and  inward  in 
the  line  of  the  upper  border  of  the  anconeeus  to  the  ole- 
1  Traite  de  la  Regeneration  cles  Os,  p.  340. 


Excision  of  the  elbow- 


l::i 


EXCISION  OF  JOINTS  AND  HONES. 


Fig.  48. 


H 


-t-A 


A 


cranon,  and  thence,  the  point  of  the  knife  touching  the 
bone,  directly  downward  along  the  inner  side  of  the  pos- 
terior aspect  of  the  ulna  for  one  or  two  inches. 

The  fascia  is  then  divided  in  the  line  of  the  incision, 
and  the  interstice  between  the  triceps  on  one  side  and  the 
supinator  longus;  radial  extensor,  and  anconeus  on  the 
other,  followed  down  to  the  capsule 
and  bone.  The  capsule  is  opened, 
and  the  humerus  denuded  on  its 
anterior  and  posterior  faces  as  far  in- 
ward as  possible,  care  being  taken  to 
maintain  the  relations  of  the  muscular 
and  ligamentary  attachments. 

The  tendon  of  the  triceps  and  the 
periosteum  of  the  ulna  are  next  de- 
tached, and  in  separating  the  former 
it  is  better  to  begin  inside  the  joint 
at  the  free  edge  of  the  olecranon. 

The  denudation  of  the  external 
condyle  and  tuberosity  of  the  humerus 
is  then  completed,  and  the  external 
lateral  ligament  entirely  detached,  the 
forearm  flexed  on  its  inner  side,  and 
the  end  of  the  humerus  dislocated  out- 
ward into  the  wound,  thus  rendering 
the  difficult  dissection  of  the  pro- 
easier.  When  this  latter  has  been 
completed,  the  periosteum  of  the  humerus  is  raised  circu- 
larly to  the  proper  height,  and  the  bone  sawn  through. 
The  head  of  the  radius  is  then  removed,  the  denudation  of 
the  ulna  completed,  and  the  bone  sawn  through  perpen- 
dicularly to  its  axis. 

\  i.i.  vm\"-  Method.     (Fig.  48,  A.) — A  longitudinal 

incision    is   begun   on    the   outer    border  of    the    humerus 

between  the  triceps  and  supinator  longus,  one  and  a-half 
inches  above  the  end  of  the  olecranon,  and  carried  down- 
ward for  a  distance  of  three  inches.     A  transverse  incision 

cutting  through  to  tin'  bone  is  next  made  from  the  lower 
end  of  the  first,  across  the  ulna  to  its  inner  border. 


Excision  of  t  h  <■  elbofl 
joint,  .v.  Nelaton.  B,  < 
Hueter. 


jecting  epitrochlea 


EXCISION   OF   THE   ELBOW-JOINT.  135 

The  triangular  Hap  thus  formed,  including  the  perios- 
teum of  the  ulna,  is  dissected  up,  the  external  lateral  and 
orbicular  ligaments  divided,  and  the  head  of  the  radius 
removed.  The  tendon  of  the  triceps  is  detached  and  the 
denudation  of  the  ulna  completed. 

The  ulna  is  projected  through  the  incision  by  bending 
the  forearm  toward  its  inner  side,  and  is  sawn  off. 

The  humerus  is  then  easily  turned  out  through  the  in- 
cision, denuded  from  below  upward  with  the  usual  precau- 
tions, and  sawn  off  at  the  desired  height. 

Loxn  Radial  Incision  (Hueter).1  (Fig.  48,  B  and 
0.) — A  preliminary  longitudinal  incision,  half  an  inch 
long,  is  first  made  directly  dowrn  upon  the  tip  of  the  epi- 
trochlea,  or  rather  on  its  anterior  side,  so  as  more  surely 
to  avoid  the  ulnar  nerve  which  lies  close  behind  it,  and  the 
muscular  attachments  and  the  internal  lateral  ligament  are 
separated  by  cutting  around  this  prominence. 

The  main  incision  is  then  made  by  entering  the  knife 
above  the  point  of  the  external  epicondyle  and  carrying  it 
straight  down  over  it,  thus  opening  the  joint  and  exposing 
the  head  of  the  radius  by  dividing  the  external  lateral 
ligament  longitudinally  and  the  orbicular  ligament  trans- 
versely. The  head  of  the  radius  is  then  removed  after 
sawing  through  its  neck. 

The  operator  then  passes  his  left  forefinger  through  the 
wound,  first  to  the  anterior  surface  of  the  humerus  to  make 
the  capsule  tense,  and  guide  the  detachment  of  it  and  the 
periosteum,  and  then  along  the  posterior  surface  under  the 
tendon  of  the  triceps  with  the  same  object. 

It  is  not  necessary  to  carry  this  dissection  very  far 
toward  the  inner  side,  because  by  dislocating  the  ulna  for- 
cibly inward  the  end  of  the  humerus  can  be  made  to  pro- 
ject through  the  radial  incision,  and  then  its  denudation 
can  be  easily  and  safely  completed,  and  the  bone  sawn 
through. 

The  end  of  the  olecranon  is  then  brought  into  the  cen- 
ter of  the  incision,  and  the  separation  of  the  triceps  begun 
at  the  upper  free  edge  of  the  process  writh  vigorous  short 
1  Deutsche  Zeitschrift  fur  Chirurgie,  2d  vol.,  p.  68. 


L36 


EXCISION  OF  JOINTS  AND   BONES. 


Fig 


cuts  into  the  substance  of  the  bone,  so  that  it  is,  as  it  were 
peeled  out  of  its  tendinous  envelope.  When  the  proper 
point  is  reached  the  bone  is  sawn  through. 

Osteoplastic  Method.  (Fig.  49.) — This  operation, 
characterized  by  primary  division  of  the  olecranon  and  its 
reunion  at  the  close  of  the  operation,  was  proposed  by 
Von  Bruns,  and  was  at  first  deemed  applicable  to  old,  ir- 
reducible, and  to  fresh  compound  dis- 
locations. Its  use  has  been  extended 
to  operations  for  foreign  bodies  in  the 
joint,  for  anchylosis,  and  finally  to 
those  for  fungous  arthritis. 

The  procedure  recommended  by  Von 
Mosetig-Moorhof  begins  by  a  trans- 
verse incision  running  from  the  lowest 
point  of  the  external  condyle  across 
the  olecranon  to  its  inner  side,  thence 
upward  alongside  the  olecranon  to  a 
point  one  inch  above  its  tip.  The  ulnar 
nerve  is  then  dissected  out  and  drawn 
aside  and  the  olecranon  divided  with 
saw  and  chisel  in  the  line  of  the  first 
part  of  the  incision.  The  flap  is  then 
drawn  aside,  the  humerus  cleared  and 
sawn  oil'  below  the  epicondyles,  the 
head  of  the  radius  removed  and  the  olecranon  scraped  and 
reunited  with  a  silver  suture. 

I  think  this  exposure  of  the  ulnar  nerve  is  unnecessary 
and  objectionable  and   have  modified   the  operation   by 

using  the  lower  two-thirds  ol'Ollier's  incision  and  making 
a  second  transverse  one    from    the    lower   end    of  the    first 

across  the  base  of  the  olecranon  and  sawing  the  latter 
through  in  this  line,  but  somewhal  obliquely  from  below 
upward,     into    the    .joint.      The    join!     was    then     further 

opened  through  the  lateral  incision,  the  external  condyle 

denuded  and  the  flap,  including  the  upper  part  of  the 
oleci anon,  turned  upward  and  inward.  This  exposed  the 
joint   freely  and  the  humerus  wa-  then  readily  denuded 

ami    -awn    oil'  through   the  epicond vie-,      'flic    radius  was 


Osteoplastic  method. 
.1.  By  externa]  incision. 
];.  Von  Mosetig-Moorhof. 


EXCISI011  OF  ANCHYLOSED   ELBOW.  137 

then  protruded  and  sawn  through  at  the  neck,  the  ole- 
cranon thoroughly  scraped,  removing  most  of  the  coro- 
Doid  process,  and  the  capsule  dissected  out.  As  the  scrap- 
ing of  the  olecranon  had  left  its  sigmoid  cavity  much  too 
large,  I  removed  a  slice  one  centimeter  thick  along  the 
Line  of  its  original  section  to  shorten  it  and  then  sutured 
the  pieces  together.  The  result  was  very  good  and  ac- 
tive extension  more  powerful  than  in  any  other  case  I 
have  seen. 

BlLATEKAL  INCISIONS. — Vogt l  speaks  highly  of  a 
method  by  which  he  accomplishes  the  same  result  with- 
out division  of  the  olecranon.  His  incision  begins  above 
the  external  condyle  and  is  carried  well  below  the  head 
of  the  radius,  dividing  the  orbicular  ligament ;  then  he 
removes  the  periosteum  from  the  radius  and  divides  it 
with  saw  or  chisel  just  above  its  tuberosity,  draws  aside 
the  edges  of  the  wound  and  explores  the  joint.  If  it  is 
extensively  diseased,  he  makes  a  second  incision  on  the 
inner  side,  beginning  above  and  a  little  behind  the  epi- 
trochlea  and  extending  about  three  inches  downward, 
then  with  a  chisel  cuts  away  the  attachments  of  the  ex- 
tensor and  flexor  muscles  from  the  condyles,  leaving  a 
shell  of  bone  attached  to  them,  draws  aside  the  soft  parts, 
divides  the  capsule,  raises  the  periosteum  from  the  hu- 
merus and  saws  off  the  end  of  the  latter.  Then,  if  neces- 
sary, he  scrapes  away  the  surface  of  the  olecranon. 

Partial  Excision. — Ollier's  and  Hueter's  methods 
are  especially  applicable  to  that  form  of  semiarticular  ex- 
cision in  which  only  the  lower  end  of  the  humerus  is  re- 
sected. INelaton's  or  Von  Langenbeck's,  or  the  lower 
part  of  Ollier's  can  be  used  for  the  removal  of  the  ends  of 
the  ulna  and  radius. 

EXCISION  OF  ANCHYLOSED  ELBOW. 

When  there  is  anchylosis  of  the  joint,  Von   Langen- 
beck's incision  can  be  used,  and  the  ulna  divided   with  a 
chain-saw  or  chisel  after  it  has  been  denuded.     The  de- 
tachment of  the  capsule  and  periosteum  is  then  proceeded 
1  Centralblatt  fiir  Chirurgie,  1882,  p.  555. 


138  EXCISION   OF  JOINTS  AND   BONES. 

with  upward,  and  the  lower  end  of  the  humerus,  with  the 

attached   ends   of  the    bones   of  the    forearm,  projected 
through  the  wound  and  sawn  oif. 

Or  the  osteoplastic  or  either  of  the  two  following  meth- 
ods may  be  employed  : 

Excision  of  Anohylosed  Elbow  (Oilier). — An  in- 
cision two  and  a-half  inches  long  is  first  made  on  the 
outer  and  posterior  side  of  the  limb  and  carried  through 
to  the  bone,  its  center  being  on  a  level  with  the  tip  of  the 
olecranon.  A  second  incision  one  and  a-half  inches  long, 
involving  the  skin  only,  is  made  on  the  inner  side  of  the 
ulnar  nerve  at  the  level  of  the  internal  border  of  the 
humerus.  The  nerve  is  found  on  dividing  the  fascia,  is 
drawn  aside  together  with  the  posterior  lip  of  the  wound 
with  a  blunt  hook,  and  is  then  entirely  out  of  the  way  of 
injury. 

The  lips  of  the  two  wounds  are  separated,  the  periosteum 
detached,  a  narrow  saw  passed  under  the  triceps,  and  the 
humerus  sawn  nearly  through  from  behind  forward,  leav- 
ing a  thin  shell  of  bone  in  front,  which  is  then  broken. 
The  conditions  are  now  those  of  a  movable  joint,  and  more 
or  less  of  the  lower  fragment  or  of  each  fragment  is  re- 
moved according  to  the  condition  of  the  bone.  The  tri- 
ceps should  be  detached  before  the  olecranon  is  divided. 

Ex<  IISION  of  A  x<  ir v u  )si;d  Elb< >w  (P.  Heron  Watson1). 
— This  method  is  intended  only  for  the  removal  of  the  artic- 
ular end  of  the  humerus,  in  cases  of  more  or  less  complete 
anchylosis  following  injury.  The  advantages  claimed  for 
it  are  that  it  leaves  the  attachments  of  the  triceps  and 
brachialis  anticus  undisturbed,  and  limits  the  area  of  the 
operation  almost  exclusively  to  within  the  capsular  liga- 
ment, and  thereby  seems  to  secure  a  more  speedy  healing 
of  the  wound.  Watson  has  used  it  in  six  cases,  in  all  of 
which  the  results  were  satisfactory. 

1.   A  linear  incision  is  made  over  the  ulnar  nerve  at  the 

inner  side   of  the   olecranon.      2.   The  nerve   is   carefully 

turned  over  the  inner  condyle.    3.  A  probe-pointed  bistoury 

i-  introduced  into  the  elbow-joint  in  front  of  the  humerus 

'  Edinburgh  Med.  Journ.,   May,  1ST::,  p.  98G. 


i:\crSION  OF  ANCHYLOSED   ELBOW 


139 


Fig.  50. 


and  then  behind  that  bone,  and  carried  upward  so  as  to 
divide  the  upper  capsular  attachments  in  front  and  behind. 
4.  A  pair  of  bone-forceps  are  next  employed  to  cut  off  the 
entire  inner  condyle  and  trochlea  of  the  humerus  [from 
above  downward] ,  and  then  introduced  in  the  opposite 
direction  [from  below  upward  and  outward] ,  so  as  to  de- 
tach the  external  condyle  and  capitellum  of  the  humerus 
from  the  shaft.  5.  The  angular 
end  of  the  humerus  is  turned  out 
through  the  incision  and  sawn  off' 
square,  6.  The  external  condyle 
and  capitellum  are  removed  partly 
by  twisting,  partly  by  dissection, 
without  any  division  of  the  skin  on 
the  outer  side  of  the  arm. 

If  there  is  dense  osseous  union 
that  cannot  be  overcome  by  flexion 
and  extension  under  chloroform, 
the  humerus  must  be  divided 
through  the  condyle  with  bone- 
pliers,  and  the  operation  completed 
as  above. 

Operative  Reduction  of  Old 
Unreduced  Backward  Dislo- 
cation of  the  Elbow.1 — The 
first  incision  is  made  on  the  outer 
side  (Fig.  50),  beginning  well  up 
(in  the  supinator  ridge  and  passing 

downward  to  and  across  the  head  of  the  radius,  and  then 
for  one  or  two  inches  posteriorly  in  the  interval  between 
the  radius  and  ulna.  Through  this  the  newly  formed  bone 
(Fig.  50,  A)  on  the  back  of  the  humerus  is  exposed  and 
chiseled  away,  and  the  outer  aspect  of  the  external  con- 
dyle freed  by  dividing  its  fibrous  attachments  to  the  radius 
and  ulna  until  the  capitellum  is  freely  exposed.  The  sides 
of  the  upper  portion  of  the  wound  are  then  retracted,  the 
olecranon  exposed,  and  the  sigmoid  cavity  cleared  of  the 
mass  of  fibrous  tissue  which,  more  or  less,  fills  it  and 
binds  it  to  the  back  of  the  humerus. 

»L.  A.  Stimson:   N.  Y.  Med.  Journ.,  Oct.  24,  1891. 


Incision  for  the  operative 
treatment  of  old  unreduced  dis- 
location of  the  elbow.  A.  Peri- 
osteal bridge  and  new  tissue 
occupying  the  posterior  surface 
of  the  lower  extremity  of  the 
humerus. 


L40  EXCISION  OF  JOINTS  AND  BONES. 

A  second  incision  is  now  made  on  the  inner  side.  It 
is  about  four  inches  long-  and  slightly  curved,  with  its 
concavity  forward,  and  it  passes  close  behind  the  internal 
epicondyle  or  its  site  if  it  has  been  broken  off  and  dis- 
placed. The  ulnar  nerve  is  found  on  dividing  the  fascia, 
and  is  carefully  drawn  forward  over  the  internal  condyle. 
The  fibrous  bands  between  the  condyle  and  olecranon  are 
divided.  If  the  epicondyle  has  been  torn  from  its  posi- 
tion and  is  attached  to  the  humerus  bigher  up,  it  must  be 
freed  and  brought  back  with  its  attached  internal  lateral 
ligament.  The  division  of  the  soft  parts  must  be  con- 
tinued until  the  trochlear  surface  of  the  humerus  is  freely 
exposed.  If  the  injury  is  of  long  standing,  and  thereby 
the  flexor  muscles  permanently  shortened,  they  must  be 
separated  from  the  internal  condyle  before  reduction  can 
lie  accomplished.  Occasionally  a  mass  of  bone  of  new  for- 
mation is  found  also  at  the  back  of  the  internal  condyle 
and  must  be  cut  away.  After  the  wound  is  closed  the  arm 
i-  dressed  at  right  angles  in  an  immobilization  apparatus. 

EXCISION  OF  THE  WRIST. 
Posteriorly  and  laterally  the  wrist  is  covered  only  by 
skin  and  tendons,  with  no  arteries  or  nerves  of  importance 
except  the  radial  artery,  which  winds  around  the  outer 
side  to  pass  again  through  the  first  metacarpal  space  to 
the  palmar  aspect  of  the  hand  and  form  the  deep  palmar 
arch  just  below  the  bases  of  the  metacarpal  bones.  Be- 
tween the  extensor  tendons  of  the  thumb  and  of  the  fore- 
finger exists  a  triangular  interval,  shown  in  Fig.  51,  the 
apex  (.f  which  is  directed  upward  and  lies  near  the  mid- 
dle of  the  dorsal  aspect  of  the  epiphysis  of  the  radius. 
Within  this  space  are  found  only  the  tendons  of  the  long 
and  -holt  extensores  carpi  radiales,  with  their  insertions 
into  the  second  and  third  metacarpals,  and  as  experience 
hae    shown    that  these  tendons  can  he  detached  or  divided 

without  prejudice  to  the  subsequent  usefulness  of  the 
hand,  the  articulation  can  he  safely  approached  through 
this  space. 

The  extensor  tendon-  are  lodged  in  deep  grooves  upon 


EXCISION  OF  THE   WRIST.  141 

the  surface  of  the  radius,  from  which  they  cannot  be 
raised  without  opening'  their  sheaths  and,  therefore,  if  it 
is  necessary  to  take  more  than  a  thin  slice  from  the  bev- 
elled end  of  the  bone,  it  .should  be  done  with  a  gouge  and 
as  a  late  step  in  the  operation.  In  this  way  it  is  possible 
to  leave  the  tendons  unhurt  and  even  unseen. 

On  the  inner  side  the  tendon  of  the  extensor  carpi  ul- 
naris  covers  the  ulna,  in  front  of  it  passes  the  flexor  carpi 
ulnaris  on  its  way  to  its  insertion  into  the  pisiform  bone 
and  the  base  of  the  fifth  metacarpal.  The  anterior  aspect 
is  occupied  by  the  numerous  and  important  flexor  ten- 
dons, the  median  and  ulnar  nerves  and  several  arteries 
or  arterial  branches  of  considerable  size.  Toward  the 
outer  side  the  tendon  of  the  flexor  carpi  radialis  passes 
through  a  groove  on  the  surface  of  the  trapezium,  to  be 
attached  beyond  the  base  of  the  second  metacarpal.  An 
ulnar  incision  should  pass  between  the  flexor  and  exten- 
sor carpi  ulnaris  at  the  anterior  border  of  the  ulna. 

Bilateral  Incisions  (Lister1).  (Figs.  51  and  52, 
.1,  />.) — All  adhesions  are  first  broken  down  by  freely 
moving  all  the  articulations  of  the  hand.  The  radial  inci- 
sion is  made  in  the  situation  indicated  by  the  line  L  L  in 
Fig.  51,  or  Fig.  52,  A.  It  commences  above  at  the  mid- 
dle of  the  dorsal  aspect  of  the  radius  on  a  level  with  the 
styloid  process.  Thence  it  is  at  first  directed  toward  the 
inner  side  of  the  metacarpophalangeal  articulation  of 
the  thumb,  running  parallel  to  the  tendon  of  the  extensor 
secundi  internodii ;  on  reaching  the  radial  border  of  the 
second  metacarpal  bone  it  is  carried  downward  longitudi- 
nally for  half  the  length  of  the  bone. 

The  soft  parts  on  the  radial  side  of  the  incision  are  next 
detached  from  the  bones  with  the  knife  guarded  by  the 
thumb-nail,  so  as  to  divide  the  tendon  of  the  extensor 
carpi  radialis  longior  at  its  insertion  into  the  base  of  the 
second  metacarpal,  and  raise  it  along  with  that  of  the  ex- 
tensor brevior,  previously  cut  across,  and  the  extensor 
secundi  internodii,  while  the  radial  artery  is  thrust  some- 
what outward.  The  trapezium  is  then  separated  from  the 
'Lancet,  1865,  p.  3:55,  slightly  abridged. 


142 


EXCISION   OF  JOISTS  AXD  BOXES. 


rest  of  the  carpus  by  means  of  cutting-forceps  applied  in 
line  with  the  longitudinal  part  of  the  incision.  The  re- 
moval of  the  trapezium  is  reserved  till  the  rest  of  the  car- 
pus has  been  taken  away.  The  soft  parts  on  the  ulnar  side 
of  the  incision  are  now  dissected  up  as  far  as  is  convenient, 


Fig.  51. 


Excision  of  the  wrist,  Lister.  A.  The  radial  artery.  /.'.  Extensor  secundi  inter- 
nodii  pollicis.  D.  Ext.  comm.  digitorum.  E.  Ext.  min.  <lig.  /•'.  Ext.  prim.  iut. 
pol.  '»'.  Ext.  oss.  met,  poll.  //.  /.  Ext.  carp.  rad.  long,  and  brev.  ft".  Ext.  carp. 
u In.     /../..  Line  of  radial  incision. 

the  extensor  tendons  being  relaxed  by  bending  back  the 

hand. 

The    knife    i-    next    entered    on    the    inner    side    of   the 

arm,  two  inches  above  the  end  of  the  ulna,  immediately 
anterior  to  the  bone,  and  is  carried  downward  between  it 

and  the  flexor  carpi  ulnaris,  and  on  in  a  straight  line  as 
far  as  to  the  middle  of  the  fifth  metacarpal  hone  at  its 
palmar  aspecl  (  Fig.  52,  11).     The  dorsal  lip  of  the  incision 

i-  raised,  and  the  tendon  of  the  extensor  carpi  ulnaris  cut 

at  its  insertion  into  the  filth  metacarpal,  and  dissected  up 

from  its  groove  in  the  ulna,  care  being  taken  to  avoid  iso- 
lating  it  from  the  integuments,  and   thus  endangering  its 


EXCISION  OF  THE   WRIST.  143 

vitality.  The  extensors  of  the  fingers  are  then  readily 
separated  from  the  carpus,  and  the  dorsal  and  internal 
ligaments  divided,  but  the  connections  of  the  tendons  with 
the  radius  are  purposely  left  undisturbed. 

The  anterior  surface  of  the  ulna  is  then  cleared  by  cut- 
tint;-  toward  the  bone,  so  as  to  avoid  the  artery  and  nerve  ; 
the  articulation  of  the  pisiform  is  opened,  if  that  has  not 
been  already  done  in  making  the  incision,  and  the  flexor 
tendons  are  separated  from  the  carpus.  While  this  is 
being  done  the  knife  is  arrested  by  the  process  of  the 
unciform  bone,  which  is  clipped  through  at  its  base  with 
pliers.  The  knife  must  not  be  carried  further  down  the 
hand  than  the  bases  of  the  metacarpal  bones,  so  as  not  to 
injure  the  deep  palmar  arch.  The  anterior  ligament  of 
the  wrist-joint  is  divided,  after  which  the  junction  between 
the  carpus  and  metacarpus  is  severed  with  cutting-pliers, 
and  the  carpus  extracted  through  the  ulnar  incision  by 
seizing  it  with  strong  forceps  and  touching  with  the  knife 
any  ligamentous  connections  that  may  remain  undivided. 

The  hand  being  now  forcibly  everted  the  articular  ends 
of  the  radius  and  ulna  will  protrude  at  the  ulnar  incision. 
If  they  appear  sound  or  only  superficially  affected,  the 
articular  surfaces  only  are  removed.  The  ulna  is  divided 
obliquely  with  a  small  saw,  so  as  to  take  away  the  carti- 
lage-covered rounded  part  over  which  the  radius  sweeps, 
while  the  base  of  the  styloid  process  is  retained.  The  end 
of  the  radius  is  then  cleared  sufficiently  to  allow  a  thin 
slice  to  be  sawn  off  parallel  to  the  general  direction  of  the 
inferior  articular  surface  and  the  articular  facet  on  the 
ulnar  side  of  the  bone  is  elipped  away  with  bone-forceps. 
If,  on  the  other  hand,  the  bones  prove  to  be  deeply 
carious,  the  pliers  or  gouge  must  be  used  with  the  greatest 
freedom. 

The  metacarpal  bones  are  next  dealt  with  on  the  same 
principle.  If  sound,  only  the  articular  surfaces  are  clipped 
off. 

The  trapezium  is  next  seized  with  forceps  and  dissected 
out,  so  as  to  avoid  cutting  the  tendon  of  the  flexor  carpi 
radialis,  which   is   firmly  bound    into   the  groove  on  its 


144 


EXCISION   OF  JOINTS  AND  BONES. 


palmar  aspect,  the  knife  being  also  kept  close  to  the  bone 
elsewhere  to  preserve  the  radial  artery.  The  articular  end 
of  the  first  metacarpal  is  then  removed.  Lastly,  the  artic- 
ular surface  of  the  pisiform  is  clipped  off,  the  rest  of  the 
hone  being  left  if  sound.  The  process  of  the  unciform  is 
also  left  if  sound.  The  radial  wound  may  he  closed  with 
sutures,  but  the  ulnar  one  must  be  kept  open  for  drainage, 
and  the  limb  must  be  bound  upon  a  splint  in  such  a  man- 
ner that  while  the  wrist  is  firmly  fixed  passive  motion  can 
be  given  regularly  to  the  fingers. 

Radial  Incision  (Oilier).  (Fig.  52,  C.) — An  incision 
involving  only  the  skin  is  begun  on  the  outer  side  of  the 
wrist,  an  inch  below  the  styloid  process  of  the  radius,  and 

Fig.  52. 


tt/AVTV 


ion  of  the  wrist.    .1.  Lister's  radial  incision.     /•'.   Lister's  ulnar  Incision. 
' .  i  Hlier.     D.  Von  Langenbeck. 

carried  upward  along  the  outer  border  of  the  bone  for  a 
greater  or  less  distance,  according  to  the  amount  to  be  re- 
moved. A  cutaneous  branch  of  the  radial  nerve  is  ex- 
posed and  drawn  aside,  the  fascia  divided,  and  the  exten- 
sor tendons  of  the  thumb  recognized.      These  tendons  are 

a  guide  which  is  easily  found.  They  are  superficial,  and 
contained  in  n  separate  groove.     On  opening  the  sheath 


EXCISION  OF  THE   WRIST.  145 

and  drawing  them  aside,  the  insertion  of  the  supinator 
longus  is  exposed,  od  the  outer  side  of  which,  and  parallel 
to  the  tendon,  the  periosteum  of  the  radius  must  then  be 
divided. 

Using  a  straight,  sharp  elevator,  the  surgeon  next  de- 
taches the  tendon  of  the  supinator,  preserving  its  relations 
with  the  periosteum,  and  then  denudes  the  lower  end  of 
the  radius  inward,  removing  periosteum  and  capsule. 
Then,  bending  the  hand  forcibly  toward  its  inner  side,  he 
separates  the  remaining  fibrous  attachments  and  dislocates 
the  lower  end  of  the  radius  outward.  The  ulna  can  be 
protruded  through  the  same  wound  and  denuded  from 
below  upward,  but  it  is  better  to  make  a  longitudinal  in- 
cision on  the  inner  side  for  this  purpose. 

The  ends  of  the  radius  and  ulna  are  then  sawn  off",  and 
through  the  gap  thus  left  the  carpal  bones  are  succes- 
sively removed  with  gouge  and  forceps. 

Dorso-RADIA L  I \( tsion  ( Von  Langenbeck).  (Fig.  52, 
/).) — The  hand  is  bent  toward  the  inner  side,  and  an  in- 
cision is  begun  at  the  ulnar  border  of  the  second  meta- 
carpal bone  near  its  middle  and  carried  upward  four 
inches,  crossing  the  ulnar  edge  of  the  tendon  of  the  exten- 
sor carpi  radialis  brevior  where  it  is  inserted  into  the  base 
of  the  third  metacarpal  bone,  and  splitting  the  dorsal 
ligament  of  the  wrist  exactly  between  the  tendons  of  the 
extensor  secundi  internodii  and  extensor  of  the  forefinger. 
This  incision  should  be  carried  down  to  the  bone,  and  the 
soft  parts  detached  on  the  radial  side  with  an  elevator; 
the  tendons,  where  they  lie  in  the  grooves,  are  raised 
bodily  with  the  periosteum,  and  their  sheaths  are  not 
opened. 

The  hand  is  flexed  so  as  to  make  the  first  row  of  carpal 
bones  present  in  the  wound  ;  the  scaphoid  is  separated 
from  the  trapezium  and  taken  out,  and  followed  in  turn 
by  the  semilunar  and  cuneiform,  the  interosseous  liga- 
ment being  cut  and  the  bones  pried  out  with  a  small  ele- 
vator.    The  trapezium  and  pisiform  are  left  if  possible. 

To  take  out  the  second  row,  the  operator  steadies  the 
round  articular  end  of  the  os  magnum  with  the  fingers  of 
10 


U6  EXCISION  OF  JOINTS  AND  BONES. 

his  left  hand,  and,  while  an  assistant  abducts  the  thumb, 
he  divides  with  a  knife  the  connection  between  the  trape- 
zium and  trapezoid,  passes  the  knife  into  the  carpo-meta- 
carpal  joint,  and  cuts  the  ligaments  on  the  dorsal  side  of 
the  ends  of  the  metacarpal  bones  while  an  aid  flexes  them. 
In  this  way  the  trapezoid,  magnum,  and  unciform  can  be 
brought  out  together. 

The  lateral  ligaments  are  then  carefully  separated  from 
the  radius  and  ulna,  the  bones  protruded  and  sawn  through. 

EXCISION  OF  THE  HIP-JOINT. 

In  this  joint,  as  in  the  shoulder,  the  disease  is  often  con- 
fined to  the  head  of  the  bone,  and  under  such  circumstances 
partial  excision  should  be  performed.  When  the  acetab- 
ulum is  diseased  the  loose  pieces  must  be  picked  out  and 
the  gouge  applied  to  the  roughened  surface.  The  line  of 
section  of  the  femur  should  pass  below  the  great  trochanter, 
however  limited  the  disease  may  be,  for  if  this  process  is 
left  it  is  liable  to  protrude  through  the  wound  and  obstruct 
the  escape  of  the  secretions.  If  the  disease  extends  be- 
yond this  point,  additional  slices  must  be  removed,  or  the 
gouge  used  until  healthy  bone  is  reached. 

The  anatomical  disposition  of  the  parts  is  such  that  the 
joint  is  best  approached  from  the  outer  and  posterior  aspect, 
the  incision  passing  over  the  top  of  the  great  trochanter. 
Different  surgeons  have  inclined  the  upper  part  of  the  in- 
cision forward  and  backward  at  various  angles,  or  have 
dissected  up  a  triangular  flap,  its  apex  directed  sometimes 
upward,  sometimes  downward. 

Saybe's  Method.  (Fig.  53,  A.) — Enter  the  point  of 
the  knife  midway  between  the  anterior  superior  spine  of 
the  ilium  and  the  top  of*  the  great  trochanter  and  drive  it 
down  to  the  bone;  then,  keeping  it  firmly  in  contact  with 
the  bone,  draw  it  in  a  curved  line  to  the  top  of  the  tro- 
chanter, midway  between  its  center  and  posterior  bonier, 
thence  forward  and  inward,  making  the  whole  length  of 
the  incision  from  four  to  eight  inches,  according  to  the 
size  of  the  thigh.  Make  sure  that  the  periosteum  is  di- 
vided throughout. 


EXCISION  OF  THE  HIP-JOIST. 


147 


Then,  drawing  aside  the  soft  parts,  divide  the  peri- 
osteum transversely  just  opposite  to,  or  a  little  above,  the 
lesser  trochanter,  carrying  the  division  as  far  as  possible 
around  the  bone.  Beginning  at  the  angle  formed  bv  the 
two  incisions,  raise  the  periosteum  on  each  side,  together 
with  its  membranous  attachment,  as  far  as  the  digital 
fossa.     Then,  substituting  a  knife  for  the  periosteal  ele- 

Fig.  53. 


Excision  of  the  hip.    A.  Sayre.    />'.  Oilier. 

vator,  divide  the  insertions  of  the  muscles  at  this  point, 
keeping  close  to  the  bone,  and  afterward  separate  the  re- 
maining periosteum  as  far  as  can  be  done  without  tearing- 
it.  Then  adduct  the  leg  slightly  and  raise  the  head  of 
the  femur  gently  out  of  the  acetabulum  ;  this  will  detach 
the  last  of  the  periosteum  and  allow  the  finger  to  be  passed 
around  the  bone  as  a  guide  for  the  saw,  which  should  be 
applied  just  above  the  lesser  trochanter. 

If  the  bone  cannot  be  readily  dislocated,  saw  it  through 
first  and  then  remove  the  head  with  the  forceps  or  elevator. 


I  18  EXCISION  OF  JOINTS  AND   BONES. 

It'  the  acetabulum  is  perforated,  the  edges  must  be 
chipped  off  very  carefully  down  to  the  point  at  which  the 
periosteum  on  the  pelvic  side  is  still  adherent. 

Ollier's  Method.  (Fig.  53,  />'.) — Oilier  makes  a 
somewhat  similar  incision.  It  begins  four  finger-breadths 
below  the  crest  of  the  ilium,  and  the  same  distance  behind 
the  anterior  superior  spine,  runs  downward  to  the  most 
prominent  part  of  the  great  trochanter,  and  thence  directly 
down  the  shaft  of  the  femur.  Its  upper  part  should  in- 
volve the  skin  and  fascia  only.  The  posterior  lip, includ- 
ing the  glutaeus  maximus,  is  drawn  back,  exposing  the 
glutseus  medius,  the  fibers  of  which  are  then  separated 
without  cutting  them.  This  permits  the  attachments  of 
the  glutseus  medius  to  be  preserved,  and  the  glutseus  min- 
imus can  be  exposed  by  drawing  apart  the  edges  of  the 
opening  made  in  the  other,  and  then  divided  in  the  same 
manner  or  drawn  forward  with  a  blunt  hook. 

The  capsule  is  split  from  the  edge  of  the  cotyloid  cavity 
to  the  digital  fossa,  and  detached  together  with  the  ten- 
dinous insertions.  The  head  of  the  femur  is  dislocated 
backward,  the  ligamentum  teres  divided,  and  the  denuda- 
tion continued  downward  to  the  lesser  trochanter.  The 
bone  is  then  protruded  and  sawn  oil'  with  a  wire  or  com- 
mon saw. 

Langenbbck's  Method. — The  thigh  is  flexed  at  an 
angle  of  45°  and  rotated  inward.  The  knife  is  entered 
ju-1  below  a  point  opposite  the  junction  of  the  upper  and 
middle  thirds  of  a  line  joining  the  posterior  superior  spine 
of  the    ilium    and   greal    trochanter;   in   other  words,  just 

below  the  most  anterior  portion  of  the  greal  sciatic  notch. 
Thence  following  the  long  axis  of  the  Hexed  lemur  it  is 
curried  in  a  straight  line  over  the  out  it  surface  of  the  -rent 
trochanter,  making  an  incision  which  penetrates  to  the 
hour  throughoul  and  i-  about  four  or  live  inches  long. 
The  glutei  are  thus  divided  in  the  direction  of  their  libers, 
the  margins  of  the  wound  retracted,  and  the  capsule  opened 
by  a  longitudinal  aided  by  a  transverse  incision  close  to 
the  edge  of  the  acetabulum.  Alter  severing  (lie  attach- 
ments of  the  muscles  t<>  the  ereat  trochanter  the  head  <»{' 


EXCISION  OF  THE  HIP-J0IN2.  149 

the  bone  is  dislocated  backward  and  brought  oul  of  the 
wound  and  sawed  off. 

Anterior  Incision. — Roser  recommends,  in  order  to 
preserve  the  trochanter,  an  anterior  incision  in  the  line  of 
the  neck  of  the  femur,  beginning  just  outside  the  crural 
nerve,  and  dividing  the  iliacus,  rectus,  sartorius,  and  tensor 
vaginse  femoris.  The  capsule  is  divided  in  the  same  line, 
the  head  turned  forward  into  the  wound  by  rotating  the 
thigh  outward,  and  sawn  off. 

Lucke  and  Schede  have  modified,  this  by  making  the 
incision  vertical  instead  of  transverse,  beginning  outside 
the  crural  nerve  a  little  below  and  to  the  inner  side  of  the 
anterior  superior  spine  of  the  ilium,  and  running  directly 
downward.  The  inner  borders  of  the  sartorius  and  rectus 
are  exposed  and  drawn  outward,  and  then  the  outer  border 
of  the  psoas-iliaeus  exposed  and  drawn  inward.  Then 
the  thigh  is  flexed,  abducted,  and  rotated  outward,  and 
the  capsule  divided. 

.V  similar  incision  and  approach  to  the  joint  may  be 
used  in  the  operative  reduction  of  old  thyroid  or  dorsal 
dislocation. 

Barker  1  employs  the  following  method  :  The  incision 
begins  on  the  front  of  the  thigh  half  an  inch  below  the 
anterior  superior  spine  of  the  ilium,  and  extends  about 
three  inches  downward  and  a  little  inward.  The  muscles 
arc  recognized  as  the  successive  layers  of  tissue  are  divided. 
The  tensor  vaginse  femoris  and  glutsei  are  drawn  to  the 
outer  side,  the  sartorius  and  rectus  to  the  inner,  and  the 
neck  of  the  femur  exposed.  The  external  cutaneous  nerve 
will  be  encountered  in  the  upper  angle  of  the  incision  ; 
lower  down  and  deeper  are  the  external  circumflex  vessels. 
The  deeper  part  of  the  incision  need  not  be  made  as  long 
as  the  more  superficial.  Any  abscess  which  may  be 
opened  should  be  thoroughly  washed  out  before  proceed- 
ing further. 

The  neck  of  the  femur  is  divided  with  a  narrow  saw 
in  the  direction  of  the  external  wound,  and  the  diseased 
head  removed  with  sequestrum-forceps.  The  acetabulum 
'Brit.  Med.  Journ..  19,  1889. 


150 


EXCISION  OF  JOINTS  AND  BOXES. 


and  all  other  parts  of  the  joint-cavity  are  explored  by  the 
forefinger,  and  any  diseased  tissue  cut  or  scraped  away. 
Mr.  Barker  fills  the  wound  with  iodoform  emulsion  and 
generally  closes  it  up  tight.  The  patient  is  placed  upon 
a  double  Thomas  splint  for  several  weeks. 

Abthbectomy  of  the  Hip- joint  by  Chiseling 
through  the  Great  Trociiaxter  (Tiling). — An  in- 
cision three  or  four  inches  long  is  made  along  the  anterior 

Fig.  54. 


Subcutaneous  dn  ision  of  iliu  neck  <>f  tin1  femur. 


border  of  the  great  trochanter,  which  is  chiseled  off  and 
laid  hack.  The  capsule  of  the  joint  is  divided  longitudi- 
nally, the  periosteum  elevated  from  the  neck  of  the  femur, 
and  the  head  of  the  femur  dislocated.  Then  the  lesser 
trochanter  is  also  chiseled  off  and  the  acetabulum  cavity 
i-  freely  accessible. 


ANCHYLOSIS    OF    THE    HIP-JOINT.1 

When  the  anchylosis  is  no1  associated  with  the  loss  of  a 
greal  pari  of  the  head  and  neck  of  the  femur — that  is, 
when  it  followe  inflammation  of  the  join!  due  to  rheuma- 

1  Tlii-  Bubject,  which  properly  belongs  under  osteotomy,  Lb  placed  here 
■  in  account  of  its  intimate  relations  with  excision  of  the  joint 


ANCHYLOSIS  OF   THE  HIP-JOINT.  151 

tism,  pyaemia,  traumatism,  or  chronic  disease  that  has  been 
arrested  at  an  early  stage — Mr.  Adams's  operation  of  sub- 
cutaneous division  of  the  neck  of  the  femur  may  be  appli- 
cable, but  usually  division  below  one  or  both  of  the 
trochanters,  or  excision  of  the  head  and  neck  is  to  be 
preferred. 

Division  below  the  lesser  trochanter  is  only  undertaken 
to  remedy  a  faulty  position  of  the  limb,  for  there  can  be 
no  question  of  establishing  a  new  joint  below  the  insertion 
of  the  psoas  and  iliacus.  It  is  doubtful  also  if  a  perma- 
nently movable  joint  can  be  obtained  by  division  at  a 
higher  point ;  it  certainly  cannot  unless  a  portion  of  the 
bone  is  removed,  and  probably  not  even  then,  for  the 
tendency  of  the  cut  ends  to  unite  after  a  time  is  very 
great. 

Subcutaneous  Division  of  the  Neck  of  the 
Femue  (Adams1). — The  only  special  instrument  needed 
is  a  saw  somewhat  resembling  a  tenotomy  knife,  the 
cutting  part  being  one  and  a-half  inches  long  and  three- 
eighths  of  an  inch  wide,  and  the  shank  about  two  and 
a-half  inches  long.     (Fig.  55.) 

A  tenotomy  knife  is  entered  a  little  above  the  top  of 
the  great  trochanter  and  pushed  straight  in  to  the  neck  of 

Fig.  55. 


Adams's  saw  for  subcutaneous  division  of  the  neck  of  the  femur. 

the  femur,  dividing  the  muscles  and  opening  the  capsule 
freely.  The  soft  parts  being  tixed  by  the  thumb  and 
lingers  of  the  left  hand,  the  knife  is  withdrawn  and  the 
saw  passed  promptly  down  to  the  bone  through  the  track 
made  by  it. 

The  bone  is  then  sawn  through  from  before  backward, 
so  that  the  line  of  section  shall  be  at  right  angles  to  the 

1  An  operation  for  bony  anchylosis  of  the  hip-joint  with  malposition 
of  the  limb,  by  subcutaneous  division  of  the  neck  of  the  thigh  bone,  by 
William  Adams.  London,  1871.  Reprinted  from  the  British  Medical 
Journal  of  December  2-4,  1870. 


152  EXCISION  OF  JOINTS  AND   BONES. 

long  axis  of  the  neck,  care  being  taken  to  avoid  cutting 
obliquely  through  the  neck,  or  in  a  direction  parallel  with 
the  -haft  of  the  bone. 

Subtrochanteric  Osteotomy.1 — An  incision  is  made 
from  one  to  two  inches  long  on  the  outer  aspect  of  the 
thigh  an  inch  to  an  inch  and  a-half  below  the  great  tro- 
chanter, according  to  the  size  of  the  patient.  It  should 
expose  the  external  surface  of  the  femur  just  below  the 
site  of  the  lesser  trochanter.  The  blade  of  the  osteotome 
is  introduced  through  this  incision,  and  the  bone  divided 
just  below  the  trochanter  minor.  After  each  stroke  of 
the  mallet  the  chisel  is  loosened  and  its  direction  slightly 
changed  to  cut  forward  or  backward.  The  bone  should 
not  be  cut  entirely  through,  but  when  it  seems  evident 
that  only  a  thin  shell  is  left  it  should  be  carefully  frac- 
tured. The  after-treatment  consists  in  simple  exten- 
sion. 

These  two  operations  are  the  ones  most  generally  em- 
ployed for  the  correction  of  deformity  following  anchy- 
losis at  the  hip  in  a  faulty  position.  Adams's  method  is, 
of  course,  only  applicable  to  those  cases  in  which  the 
femur  still  possesses  a  neck,  and  inasmuch  as  the  disease 
which  most  frequently  calls  for  this  kind  of  interfer- 
ence— namely  tuberculosis — generally  causes  more  or 
less  destruction  of  the  head  and  neck  of  the  femur, 
the  second,  subtrochanteric  osteotomy,  has  a  wider 
use. 

Excision. —  Posterior  incision  as  above  described,  with 
such  modifications  as  may  be  made  necessary  by  disloca- 
tion; division  of  the  neck  with  the  saw,  if  possible; 
otherwise  with  the  chisel  :  then  removal  of  the  head,  or 
wlrnt  remains  of  it,  by  chiseling. 

The  upper  end  of  the  bone  is  then  lodged  In  the  acetab- 
ulum, after  subcutaneous  division  of  such  muscles  and 
-oft  parte  as  interfere  and  removal  of  the  upper  part  of 
the   trochanter,  if  necessary.     Traction    by  weight  and 

pulley  musl    be  kept   up  for  a  long  time. 

'i, miii-  "Science  and  Practice  of  Sprgery,"  1886. 


EXCISION  OF  THE  KNEE-JOINT. 


153 


EXCISION  OF  THE  KNEE-JOINT. 

This  should  always  be  complete  to  this  extent,  that  a 
slice  should  be  taken  from  each  bone,  but  it  is  not  always 
accessary  to  remove  the  entire  articular  surface  of  the 
femur.  In  children  the  amount  removed  should  be  as 
small  as  is  consistent  with  the  removal  of  all  that  is  dis- 
eased. The  patella  may  be  dissected  out  and  removed 
entire,  or  the  diseased  portions  extirpated  with  the  gouge 
or  rongeur,  or  it  may  be  sawn  through  parallel  with  its 
articular  surface.  As  a  general  thing 
the  latter  method  is  preferable,  unless 
the  bone  is  so  extensively  affected  that 
the  preservation  of  even  its  anterior 
surface  is  incompatible  with  a  thor- 
ough removal  of  all  the  disease. 

As  anchylosis  should  always  be 
aimed  at,  the  incision  may  cross  the 
front  of  the  joint  and  divide  the  liga- 
mentum  patella?  or  the  patella. 

Semilunar  Incision.  (Fig.  56,  .1.) — 
The  knife  is  entered  on  one  side  of 
the  limb  at  the  posterior  part  of  the 
condyle  and  carried  across  midway 
between  the  patella  and  the  tuberosity 
of  the  tibia  to  a  corresponding  point 
upon  the  other  side.  This  incision 
should  extend  down  to  the  bone 
throughout,  dividing  the  ligamentum 
patellae.  The  flap  is  reflected,  the  crucial  ligaments  divided 
close  to  their  attachment  to  the  tibia,  the  lateral  ligaments 
divided,  the  end  of  the  femur  cleared  as  far  as  may  be  nec- 
essary, with  especial  care  for  the  safety  of  the  popliteal 
vessels,  protruded  through  the  wound  and  sawn  off".  The 
line  of  section  must  be  parallel  to  the  line  of  the  artic- 
ulation, not  at  a  right  angle  to  the  axis  of  the  shaft,  for 
that  is  directed  inward  and  downward.  If  necessary,  ad- 
ditional slices  of  the  bone  are  removed,  or  the  gouge  is 
used.     All  the  articular  cartilages  should  be  removed. 

The  end  of  the  tibia  is  next  projected,  cleaned,  and  sawn 


Excision  of  the  knee-joint. 
.1.  Semilunar  incision.  B. 
<  >llier's  incision. 


l.M  i:\risin\    OF  JnlXTS   AM)   JiOXES. 

off  about  halt'  an  inch  below  its  upper  surface.  In  the 
young  every  effort  must  be  made  to  save  each  conjugal 
cartilage  ami  the  adjoining  portion  of  the  epiphysis  in  order 
that  the  growth  of  the  limb  may  not  be  checked. 

In  sawing  the  bones  it  is  best  not  to  make  a  complete 
section  with  the  saw,  but  to  stop  a  little  short  of  the  pos- 
terior surface  and  complete  the  separation  by  fracturing 
what  is  left. 

Finally,  the  patella  is  taken  out,  and  diseased  portions 
of  the  synovial  membrane  scraped  or  clipped  off,  or  the 
articular  surface  of  the  patella  may  be  removed  with  the 
saw  ur  rongeur,  and  the  anterior  bony  shell  which  is  at- 
tached to  the  quadriceps  tendon  left.  The  operation  is 
completed  by  suturing  in  position  the  divided  ligamentum 
patelbe. 

Transverse  Incision. — The  incision  should  cross  the 
patella  at  or  just  below  its  center  and  extend  beyond  the 
center  of  the  condyle  on  each  side  ;  at  each  end  should  be 
made  a  longitudinal  incision  extending  two  inches  above 
ami  one  inch  below  the  transverse  one  ;  the  patella  is  then 
divided  at  its  center  transversely,  the  fragments  turned  up 
and  down,  and  the  joint  thus  opened  and  cleaned. 

At  the  close  of  the  operation  the  patella  is  replaced  and 
united  with  sutures  ;  the  patella  maybe  entirely  removed  ; 
or,  in  the  first  place,  after  exposing  the  bone,  the  patella 
may  be  dissected  out,  and  at  the  close  of  the  operation  the 
quadriceps  tendon  reunited. 

A.RTHRECTOMY,  OR  EXTIRPATION  OF  Till:  K  NEE- 
JOINT. — This  term  ha-  been  given  to  the  systematic  re- 
moval of  the  synovial  membrane  and  any  small  portions 
of  the  rest  of  the  articulation  which  may  on  inspection  be 
found  to  be  diseased.  The  above-described  semilunar  in- 
cision 18  employed,  and  the  anterior  flap  containing  the 
patella  reflected.  After  removing  all  pulpy  and  degener- 
ated tissue  in  the  subcrural    pouch'the  lateral  and   crucial 

ligaments,  if  necessary,  are  cut,  although  the  latter  should 
l.e  spared  whenever  possible.  The  joint  is  thus  thor- 
oughly exposed,  and  all  the  diseased  parts  in  its  interior 

excised,  together  with  the  semilunar  cartilages.      Foci  of 


KXClsloy    OF   TllF   AS'KLE-.IOINT. 


155 


Fig. 


inflammation  in  the  bone  must  be  removed  with  the  sharp 
spoon.  The  field  of  operation  is  then  flushed  out  with 
some  antiseptic  solution,  the  ligamentum  patellae  sutured 
in  position,  and  the  cutaneous  wound  loosely  united. 
Whenever  it  is  deemed  desirable  drainage-tubes  may  be 
inserted  in  the  posterior  angles  of  the  incision.  Immobil- 
ization of  the  leg  in  extension  must  bo  maintained  for  sev- 
eral weeks. 

EXCISION  OF  THE  ANKLE-JOINT. 

The  results  of  excision  of  the  ankle-joint  have  been,  on 
the  whole,  unfavorable.  When  the  operation  has  been 
undertaken  on  account  of  caries,  the  disease  has  usually 
returned  in  the  tarsal  bones,  and 
rendered  secondary  amputation 
necessary.  When,  on  the  other 
hand,  it  has  been  performed  on  ac- 
count of  injury,  secondary  amputa- 
tion has  been  frequently  required, 
and  the  position  of  the  foot  in  the 
cases  that  recovered  has  usually 
been  faulty. 

As  anchylosis  is  to  be  expected, 
the  rule  in  excision  is  to  remove 
the  smallest  possible  amount  of 
bone,  and  to  make  partial  instead 
of  complete  excision  when  the  dis- 
ease does  not  extend  to  the  whole 
joint.  The  retention  of  one  or  the 
other  malleolus  is  a  great  help  in 
preventing  shortening,  and  in  the 
use  of  a  plaster  splint.  The  inter- 
osseous membrane  between  the 
tibia  and  fibula  must  be  preserved 
carefully.  It  not  only  has  a  great  tendency  to  ossify,  but 
also  seems  to  favor  the  reproduction  of  bone. 

Operation  (Total  Excision). — An  incision  involving 
only  the  skin  is  begun  two  inches  above  the  external  mal- 
leolus and  a  little  behind  the  middle  of  the  fibula,  carried 


Excision  of  ankle. 


156  EXCISION   OF  JOISTS  AND   BONES. 

directly  down  to  the  end  of  the  bone,  and  thence  forward 
and  slightly  upward  toward  the  instep  for  an  inch  (Fig. 
57).  The  periosteum  covering  the  fibula  is  divided 
throughout  and  dissected  up  from  the  bone  with  the  at- 
tachment of  the  lateral  ligaments,  especial  care  being  taken 
not  to  open  the  sheath  of  the  peroneal  muscles  at  the  pos- 
terior border  of  the  malleolus,  and  to  remove  all  the  thick 
periosteum  and  the  interosseous  membrane  on  the  inner 
side.  If  necessary,  a  transverse  liberating  incision  may 
be  made  through  the  periosteum  at  the  upper  end  of  the 
cut.  The  bone  is  then  divided  with  a  keyhole  saw  or 
chisel,  the  upper  end  of  the  lower  fragment  drawn  out  of 
the  wound  to  expose  and  facilitate  the  separation  of  the 
remaining  attachments,  and  the  piece  removed. 

The  soft  parts  are  then  held  out  of  the  way  with  retrac- 
tors, and  the  upper  articular  surface  of  the  astragalus 
sawn  off  with  the  keyhole  saw,  but  not  removed. 

The  foot  is  next  turned  upon  its  outer  side,  and  a  longi- 
tudinal incision  two  or  three  inches  long  made  along  the 
side  of  the  tibia,  ending  half  an  inch  below  the  tip  of  the 
malleolus,  where  it  is  then  crossed  by  a  short  horizontal 
one  involving  the  skin  only.  The  periosteum  of  the  tibia 
is  divided  in  the  line  of  the  incision  and  transversely  at 
its  upper  end,  and  dissected  off,  the  bone  sawn  through, 
and  the  piece  removed.  Langenbeck  makes  the  line  of 
section  oblique  downward  and  outward,  because  it  is 
easier  to  do  so,  but  most  surgeons  prefer  to  have  it  trans- 
verse. The  upper  part  of  the  astragalus,  which  has  been 
previously  sawn    off,  is    then    removed    through    the    same 

incision. 

The  gouge  is  used  to  scrape  away  any  diseased  parts 
found  on  the  cut  surface  of  the  astragalus,  or  the  bone 
may  be  seized  with  strong  forceps  and  dissected  out 
int  i  rely. 

If  the  injury  has  affected  the  a-tragalus  only  (as  in 
-nine  gunshot  wounds),  its  splinters  are  best  removed 
through  a   longitudinal   incision  upon  the  dorsum  of  the 

foot  between  tic  extensor  tendon-  of  the  first  and  second 
t,„  a, 


EXCISION  OF  THE  ANKLE-JOINT.  157 

Vogt's  Method,  by  Removal  of  the  Astragalus. 
(Fig.  69.) — A  serious  objection  to  the  use  of  the  preceding 

operation  in  cases  of  tuberculous  disease  lies  in  its  insuf- 
ficient exposure  of  the  interior  of  the  joint  to  view,  and  it 
has  been  proposed  by  Hueter  to  return  to  the  old  method 
of  an  anterior  transverse  incision  with  division  of  all  the 
extensor  tendons,  and  by  Busch  to  open  the  joint  by  cut- 
ting across  the  sole  and  sawing  through  the  calcaneum. 
Vbgt,1  however,  has  proposed  and  employed  another 
method,  which  avoids  the  extensive  division  of  the  soft 
part  and  which  enables  the  surgeon  to  explore  the  joints 
thoroughly,  and,  if  necessary,  to  excise  the  synovial 
membrane.  It  consists  in  primary  methodical  extirpation 
of  the  astragalus  without  resection  of  the  malleolus. 

Operation. — A  longitudinal  incision  on  the  outer  side  of 
the  extensor  tendons,  three  or  four  inches  long,  beginning 
above  between  the  tibia  and  fibula,  and  ending  below  at 
the  line  of  the  calcaneo-cuboid  joint ;  after  division  of  the 
fascia  the  tendons  are  raised  in  their  sheaths,  carefully  sep- 
arated from  the  underlying  parts,  and  strongly  retracted 
to  the  inner  side.  The  extensor  brevis  is  then  cut,  the 
outer  side  of  the  incision  retracted,  the  capsule  split  longi- 
tudinally to  its  full  extent  and  separated  on  both  sides  from 
the  bone  with  knife  and  elevator,  the  head  and  neck  of 
the  astragalus  cleared,  and  the  astragalo-scaphoid  ligament 
divided. 

A  second  incision  is  made  from  a  point  somewhat  below 
the  center  of  the  first  backward  below  the  external  malle- 
olus, dividing  everything  down  to  the  astragalus,  but  spar- 
ing the  peroneal  tendons.  The  foot  is  then  supinated,  the 
anterior  ligaments  cut  away  from  the  external  malleolus, 
and  the  strong  interosseous  ligament  divided  by  thrusting 
a  small  strong  knife  into  the  groove  between  the  astragalus 
and  calcaneum.  The  head  of  the  astragalus  is  then  drawn 
forcibly  outward  with  a  stout  hook,  while  the  foot  is  supi- 
nated, the  deep  portion  of  the  internal  lateral  ligament  cut 
by  passing  a  knife  between  the  malleolus  and  the  astragalus, 
the  latter  drawn  forward  into  the  incision,  and  its  poste- 
rior attachments  cut. 

1  Centralblatt  fiir  Chirurgie,  1883,  p.  289. 


1 .-» 


EXCISION  OF  JOINTS  AND  BONES. 


The  remainder  of  the  operation  will  vary  with  the  ex- 
tent and  character  of  the  disease.  All  the  adjoining  bones 
arc  freely  exposed  to  inspection,  and  can  be  scraped, 
gouged  out,  or  sawn  off. 

1  have  found  the  execution  of  this  operation  easy,  even 
when  the  capsule  was  much  thickened  by  disease,  and  its 
exposure  of  the  interior  of  the  joint  is  very  satisfactory. 

OSTEOPLASTIC  EXCISION  OF  THE  FOOT   (HEEL  AND 
ANKLE)   (MIKULICZ). 

This   ingenious   operation,  the   results   of  which  have 

proved  very  satisfactory,  was  introduced  by  Mikulicz  in 


Fig.  58. 


0  Icopliulic  excisiou  of  Hie  foot,    (Mikulicz.) 


OSTEOPLASTIC  EXCISION  OF  THE  FOOT.        159 

1881. l    It  is  specially  applicable  to  cases  in  which  the  in- 
tegument about  the  heel  has  been  extensively  destroyed. 

Operation.  (Fig.  58.) — Abdominal  decubitus.  An  in- 
cision beginning  a  little  in  front  of  the  tubercle  of  the 
scaphoid  is  carried  directly  across  the  sole  of  the  foot  to  a 
point  just  behind  the  base  of  the  fifth  metatarsal  bone. 
From  each  end  of  this  one  another  incision  is  carried  back- 
ward and  upward  to  the  base  of  the  corresponding  malle- 
olus, and  the  upper  ends  of  the  last  two  incisions  arc  then 

Fig.  59. 


External  incision  for  the  operative  treatment  of  old  unreduced  Pott's  fracture. 
The  astragalus  is  displaced  backward.  Its  articular  surface  is  partially  in  contact 
with  the  new  bone  developed  under  the  periosteal  bridge  at  the  lower  end  of  the 
posterior  surface  of  the  tibia. 


united  by  a  fourth  which  passes  horizontally  across  and 
divides  the  tendo  Achillis.  In  all  the  incisions  the  knife 
is  made  to  touch  the  bone  throughout. 

The  lateral  ligaments  of  the  ankle  arc  next  divided,  the 
joint  opened  from  behind,  and  the  calcaneum  and  astra- 
galus carefully  dissected  from  the  tissues  in  front  of  the 
incisions  and  removed  by  disarticulating  at  the  medio- 
tarsal  joint. 

Finally,  the  malleoli  and  lower  articular  surface  of  the 
tibia  and  the  posterior  portion  of  the  cuboid  and  scaphoid 

1  Archiv  fur  klinische  Chirurgie,  Vol.  XX  YL,  p.  191. 


160  EXCISION  OF  JOINTS  AND  BOXES. 

are  sawn  off,  as  shown  by  the  dotted  lines  in  the  figure, 
the  cut  being  made  from  behind  forward. 

The  cut  surfaces  of  bone  are  then  brought  into  apposi- 
tion and  fastened  together  with  nails  or  sutures,  and  the 
wound  closed.     Fig.  58,  B,  represents  the  result. 

Operative  Treatment  of  Old  Unreduced  Pott's 
Fracture.1 — The  Esmarch  rubber  bandage  or  tourni- 
quet is  applied  and  tied  below  the  knee.  An  incision 
is  begun  on  the  outer  side  three  inches  above  the  ankle, 
and  carried  down  along  the  front  of  the  fibula  to  the  mal- 
leolus, and  thence  in  a  curve  forward  toward  the  fifth 
metatarsal  (Fig.  .VJ).  The  seat  of  the  fibular  fracture  is 
exposed,  and  the  lower  fragment  again  separated  with  the 
chisel. 

Fig.  60. 


[nternal  incision  for  the  operative  treatment  of  old  unreduced  Pott's  fracture. 
11m  astragalus  is  represented  as  displaced  backward, 

A  second  longitudinal  incision  about  five  inches  lone  is 
made  over  the  inner  side,  extending  past  the  malleolus  to 
the  tubercle  of  the  scaphoid  (Fig.  60).  Through  it  the 
mass  of  new  tissue  that  has  formed  between  the  astragalus 
and  the  internal  malleolus  is  removed  or  the  broken  and 
displaced  malleolus  is  mobilized. 

By  now  working  through  both  incisions  the  hack  of  the 
lower  end  of  the  til>i:i  can  be  WnA  of  sncli  cicatricial  tissue 
'Stimson;    N.  Y.  Medical  Journal,  June  25,  1892. 


EXCISIOH    OF  THE  SUPERIOR  MAXILLA.         161 

or  new  bone  as  has  formed  there,  and  the  foot  so  mobilized 
that  it  can  be  brought  back  to  its  proper  place.  The  peri- 
osteum and  ligaments  are  sutured  in  position  with  catgut, 
the  wound  loosely  closed  without  drainage,  and  after  ap- 
plying a  bulky  dressing  the  tourniquet  is  removed. 

EXCISION  OF  THE  BONES  AND  SMALLER 
ARTICULATIONS. 

EXCISION  OF   THE   SUPERIOR  MAXILLA. 

This  operation  may  be  required  on  account  of  malig- 
nant tumors  of  the  bone  or  antrum,  or  to  give  access  to  the 
base  of  implantation  of  a  naso-pharvngeal  polyp. 

In  total  excision  the  bony  connections  that  require  to  be 
divided  are  :  (1)  The  one  with  the  malar  bone  below  the 
outer  angle  of  the  orbit.  (2)  That  with  the  opposite  bone 
along  the  center  of  the  hard  palate.  (3)  Those  formed  by 
the  nasal  process  near  the  inner  angle  of  the  orbit ;  and  (4) 
that  with  the  palate  bone  and  pterygoid  process  of  the 
sphenoid  (Fig.  (31).  The  first  may  be  divided  by  nick- 
ing the  anterior  surface  of  the  bone  with  a  saw,  and  com- 
pleting the  division  with  cutting  forceps,  or  with  chisel  and 
mallet,  or  by  passing  a  Gigli  wire  around  it,  through  the 
spheno-maxillary  fissure  in  the  orbit  and  zygomatic  fossa. 
The  second  is  divided,  after  having  drawn  one  or  both  in- 
cisor  teeth,  by  means  of  a  saw  passed  into  the  nostril,  or 
with  cutting  forceps  with  long  narrow  blades,  or  a  chisel. 
The  third  is  easily  divided  with  forceps  or  a  chisel,  and 
the  fourth  by  twisting  the  bone  downward  after  all  the 
other  connections  have  been  severed. 

The  periosteum,  covering  the  floor  of  the  orbit,  is  thick 
and  easily  detached  ;  that  on  the  hard  palate  is  thick  and 
difficult  of  removal,  on  account  of  the  irregularities  of  the 
surface.  There  is  but  little  danger  of  injury  to  the  in- 
ternal maxillary  artery,  and  it  is  seldom  necessary  to  ap- 
ply more  than  one  or  two  ligatures  to  its  divided  branches. 
Oozing  is  arrested  by  packing  with  aseptic  or  iodoform 
gauze. 

11 


162 


EXCISION  OF  JOINTS  AND   BONES. 


In  partial  excision  the  orbital  plate  is  left,  the  line  of 
division  of  the  bone  passing  through  the  anterior  wall  of 
the  antrum  from  the  nostril  to  the  lower  corner  of  the 
union  with  the  malar  bone.  The  remaining  attachments 
are  then  broken  as  before.     There  are  also  other  varieties 

Fig.  01. 


Lines  of  bony  division  in  the  different  operations  "'i  the  superior  and  inferior 
\   I'.. '  .    ["otal  excision  of  the  superior  maxilla.     I>.  Meckel's  operation. 
.  ri.r-  operatl  >n.     I  -  I     Langenbeck'a  operation  i"'»r  naso-pharyngeal  poly- 
Excision  mi'  Inferior  maxilla.    II.  Removal  of  a  portion  of  the  ■ 
(•    -/.,  for  epulis).    I.  Esmarch's  operation  for  anchylosis  of  Inferior  maxilla. 

..I'  partial  excision  for  the  removal  of  naso-pharyngeal 
polypi;  removal  of  the  nasal  process  with  the  nasal  bone; 
removal  of  pari  of  the  hard  palate  I  Nelaton) ;  and  tempo- 
rary removal  of  different  portion-,  preserving  the  connec- 


EXCISION  OF  THE  SUPERIOR  MAXILLA.         163 

tion  with  the  soft  parts,  and  replacing  them  after  the  polyp 
has  been  removed. 

The  incisions  that  have  been  proposed  may  be  classed 
as  (1)  external  and  (2)  median  ;  the  former  extending 
from  the  angle  of  the  mouth  upward  and  outward  to  the 
malar  bone  ;  the  latter  passing  from  or  near  the  middle 
of  the  lip  up  toward  the  inner  angle  of  the  eye.  The 
former  are  open  to  the  objections  that  they  divide  the 
branches  of  the  facial  nerve,  endanger  Steno's  duct  and 
leave  a  conspicuous  scar.  The  preference  is  now  gener- 
ally accorded  to  the  median  incisions.  These  follow  the 
outline  of  the  side  of  the  nose  more  or  less  closely  and 
some  of  them  are  supplemented  by  a  transverse  incision, 
passing  a  quarter  of  an  inch  below  the  lower  margin  of 
the  orbit.  For  partial  excision  Guerin  recommends  an 
incision  passing  from  the  side  of  the  wing  of  the  nose 
along  the  naso-labial  fold  to  the  angle  of  the  mouth 
(Figs.  61,  63). 

In  order  to  avoid  the  swallowing  of  blood,  it  is  well 
not  to  carry  the  incision  through  the  lip  or  divide  the 
gingivo-labial  fold  until  after  the  anterior  face  of  the  bone 
has  been  denuded  as  far  as  possible. 

It  is  possible  to  remove  the  superior  maxilla  through 
the  mouth  without  making  any  cutaneous  incisions,  but 
it  is  a  very  difficult  and  painful  operation  and  the  hemor- 
rhage is  most  embarrassing.  Larghi  has  removed  both 
bones  through  the  mouth,  upon  the  cadaver,  and  says 
it  is  easier  to  remove  both  together  than  one  alone  in 
this  way. 

In  simultaneous  excision  of  both  superior  maxillte,  the 
same  incisions  may  be  made  on  both  sides  as  for  the  re- 
moval of  only  one,  or  Dieffenbach's  median  incision  may 
be  made  along  the  ridge  of  the  nose  and  the  middle  of 
the  upper  lip. 

Operation  by  a  Median  Incision.  (Fig.  62,  B.) — The 
usual  method  of  operation  is  as  follows  :  The  incision  is 
begun  half  an  inch  below  the  inner  canthus  of  the  eye. 
It  is  carried  down  the  line  of  the  junction  of  the  nose 
with  the  nice  and  along  the  groove  which   limits  the  ala 


164 


EXCISION   OF  JOISTS  AXD   BONES. 


nasi,  thence  transversely  to  the  septum  and  so  down  to 
the  free  border  of  the  lip  in  the  median  line. 

This  Incision  may  be  supplemented,  if  accessary,  by  one 
joining  it  at  the  inner  canthus  and  following-  the  edge  of 
th 'bit  outward. 

The  cartilage  of  the  nose  is  separated  from  the  bone 
and  reflected  inward  with  the  small  internal  flap,  the  edge 
of  the  orbit  cleared  and  the  external  flap  dissected  out- 
ward as  far  as  to  the  malar  bone  above  and  the  tuberosity 
of  the  maxilla  below,  if  possible,  the  infra-orbital  nerve 
being  divided  at  its  point  of  emergence  from  the  foramen. 

Fi.i.  62. 


Excision  of  Buperior  maxilla.    .1.  Externa]  incision.    B.  Nfilaton's  incision,    c. 
Boeckel's  incision. 

The  periosteum  of  the  floor  of  the  orbit  is  then  detached 
with  the  handle  of  the  knife,  as  far  as  the  spheno-maxil- 
larv  fissure,  the  malar  process  or  bone  cut  through  with 
iIm-  -aw  or  forceps,  and  the  thin  plate  of  bone  forming  the 
floor  of  the  orbit  divided  with  the  knife  obliquely  inward 
and  forward  from  the  anterior  end  of  the  sphenomaxil- 
lary fissure.  The  superior  maxillary  nerve,  which  can  !><■ 
readily  distinguished  through  the  bone,  should  also  be 
divided  as  far  back  as  possible,  finally,  the  nasal  proc- 
ess is  divided. 

The  incision  i-  then  carried  through  the  lip,  and  the 
detachmeni  of  the  externa]  -oft  parts  completed. 

The   mucous   membrane  of  the  roof  of  the  mouth  is 

divide. I    transversely  on  a  line  with   the    last    molar  tooth. 


EXCISION  OF  THE  SUPERIOR  MAXILLA. 


it;:, 


and  longitudinally  in  the  median  line.  An  incisor  tooth 
is  then  drawn,  and  the  hard  palate  divided  with  saw  or 
forceps  close  to  the  septum. 

If  the  mucous  membrane  of  the  roof  of  the  mouth  is  not 
diseased  it  may  be  retained.  Instead  of  the  incisions 
through  it  just  mentioned,  one  is  made  along  the  inner 
border  of  the  alveolar  process,  its  edge  raised,  and  the 
membranes  detached  inward  and  backward  to  the  median 
line.      After  the  removal  of  the  bone  it  unites  with  the 


Fig.  63. 


A.  Guerin's  incision  for  partial  removal  of  superior  maxilla.  B.  Oilier' s  incision 
for  subperiosteal  excision  of  superior  maxilla.  C.  Dieffenbach's  median  incision 
for  removal  of  both  bones.  L.  Langenbeck's  incision  for  naso-pbaryngeal  polypus. 
K.  Boeckel's  incision  for  uaso-pharyngeaJ  polypus. 

cheek,  closes  in  the  mouth  as  before,  and  may  become 
strengthened  by  a  deposit  of  bone. 

Finally,  the  bone  is  grasped  with  strong  forceps, 
twisted  downward  to  break  its  posterior  connections,  and 
removed,  generally  bringing  with  it  part  of  the  palate 
bone,  the  hamular  process  of  the  pterygoid,  and  some  at- 
tached muscular  fibers. 

Subperiosteal  Excision  (Oilier). — This  method  can  be 
employed  with  the  median  incision  above  mentioned,  but 
Oilier  prefers  an  external  one  (Fig.  63,  B). 

An  incision  is  made  from  the  middle  of  the  malar  bone 
to  a  point  on  the  upper  lip  one-third  of  an  inch  from  the 


166  EXCISION  OF  JOINTS  AND   BONES. 

angle  of  the  mouth,      [f  necessary,  a  second  incision  must 
be  made  at  the  middle  of  the  lip  and  carried  up  around  the 

nostril. 

An  incision  in  the  mucosa  is  begun  on  the  outer  surface 
at  the  interval  between  the  second  incisor  and  the  canine 
tooth  (he  does  not  remove  the  intermaxillary  bone,  that 
which  supports  the  incisor  teeth)  close  to  the  edge  of  the 
gum,  carried  back  around  the  last  molar,  then  forward  on 
the  inside  to  a  point  corresponding  to  that  at  which  it  was 
begun,  and  thence  obliquely  backward  to  the  median  line. 
A  short  incision  through  the  periosteum  is  next  made 
from  the  anterior  external  extremity  of  the  former  upward 
and  inward  to  a  point  a  quarter  of  an  inch  external  to  the 
anterior  nasal  spine. 

The  periosteum  of  the  anterior  surface  is  then  detached 
with  an  elevator,  care  being  taken,  however,  to  divide  the 
infra-orbital  nerve  with  a  knife  at  its  point  of  emergence, 
and  the  denudation  is  carried  along  the  floor  of  the  orbit. 
Unless  it  is  necessary  to  remove  the  nasal  process  of  the 
maxilla,  the  lachrymal  sac  and  duct  can  be  left  uninjured 
and  adherent  to  the  periosteum. 

The  periosteum  of  the  roof  of  the  mouth  is  then  separated 
from  without  inward  as  far  as  the  median  line. 

The  nasal  and  malar  processes  are  divided  with  forceps, 
chisel,  or  chain-saw,  as  before  described,  the  canine  tooth 
drawn,  the  edge  of  the  chisel  Inserted  in  the  gap  left  by  it, 
and  pressed  gently  backward  and  inward  to  the  median 
line,  thence  directly  backward  along  the  suture. 

The  bone  is  then  twisted  out,  the  palatal  sutured  to  the 
external  periosteum,  and  the  wound  closed. 

Excision  of  the  Portion  of  the  Superior  Maxilla  Lying 
Below  the  Infra-orbital  Foramen  (Guerin's  Operation).  (Figs. 
61,  E  ( '.  63,  A). — An  incision,  slightly  convex  externally, 
is  made  from  the  ala  of  the  nose  to  the  angle  of  the  mouth, 
following  the  crease  Usually  present  in  the  features  at  this 

situation.     The  alveolar  mucous  membrane  is  divided  at 

the  point  of  reflection  on  to  the  cheek  from  the  level  of 
the  lasl  molar  tooth  to  the  middle  line  anteriorly.  The 
-oft   parte  are  dissected  up  and  the  nostril  opened  in  front. 


EXCISION   OF  THE  SUPERIOR   MAXILLA.        167 

A  narrow  saw  is  passed  through  the  Dares  and  the  maxilla 
sawn  horizontally  outward.  The  saw  cut  passes  below 
the  infra-orbital  canal  well  above  the  teeth  and  through  the 
malar  process  and  maxillary  tuberosity  ;  or  the  bone  may 
be  chiseled  through  on  this  line.  The  soft  palate  is  de- 
tached i'rom  the  hard  by  a  transverse  incision  at  the  last 
molar  tooth.  A  middle  incisor  tooth  is  next  removed  and 
the  hard  palate  divided  in  the  median  line  with  a  saw, 
chisel,  or  forceps  introduced  through  the  nostril.  The 
detached  piece  of  bone  is  loosened  with  a  periosteal  eleva- 
tor and  wrenched  out. 

This  operation  may  be  performed  subperiosteally  (usu- 
ally for  naso-pharyngeal  polypus),  either  by  the  above- 
described  or  by  a  median  incision.  The  muco-periosteum 
is  divided  along  the  free  margin  of  the  inner  and  outer 
faces  of  the  alveolar  process  on  the  affected  side,  from  the 
anterior  nasal  spine  around  behind  the  last  molar  tooth, 
and  detached  to  the  middle  line  of  the  hard  palate  and  to 
its  posterior  border  and  upward  to  near  the  infra-orbital 
foramen  on  the  outer  surface  of  the  superior  maxilla. 
The  lower  half  of  the  latter  is  next  removed  as  indicated 
above,  and  at  the  close  of  the  operation  the  mucous  mem- 
brane is  united  as  far  as  possible  by  sutures,  thus  shutting 
off  the  nasal  from  the  oral  cavity. 

This  operation  affords  an  excellent  view  of  the  naso- 
pharynx. 

Removal  of  the  Superior  Maxilla  Above  the  Alveolar 
Process  (Berard's  Operation). — The  median  incision  is 
used  from  below  the  inner  canthus  of  the  eye,  following 
the  junction  of  the  nose  and  face  through  the  center  of 
the  upper  lip  (Fig.  62,  B).  The  soft  parts  on  the  affected 
side  are  raised  as  for  total  extirpation  of  the  maxilla  and 
the  periosteum  of  the  floor  of  the  orbit  is  detached  as  far 
as  the  sphcno-maxillary  fissure.  The  malar  process  is  di- 
vided and  then  the  orbital  plate  inward  and  forward  from 
the  anterior  end  of  the  spheno-maxillary  fissure.  The  su- 
perior maxillary  nerve  is  cut  as  far  back  as  possible  and, 
finally,  the  nasal  process. 

A  horizontal  saw-cut  is  then   made  outward  from  the 


168  EXCISION  OF  JOINTS  AND   BONES. 

nose  above  the  alveolar  process.  Any  adherent  structures 
between  the  outer  extremity  of  this  cut  and  that  through 
the  malar  process  are  freed  with  the  knife  or  periosteal 
elevator  and  the  piece  of  bone  thus  mapped  out  is  pried 
or  wrenched    away.     The   sound  aveolar  process  is  left 

in  8ttll. 

SIMULTANEOUS  EXCISION  OF  BOTH  SUPERIOR 
MAXILLA. 

An  incision  may  be  made  from  each  angle  of  the  mouth 
to  the  malar  bone  and  the  broad  flap  reflected  toward  the 
forehead,  or  Dieffcnbach's  incision  made  along  the  ridge 
of  the  nose  (Fig.  63,  C),  with  or  without  a  transverse  one 
passing  across  it  and  below  the  margin  of  each  orbit. 

The  bones  are  removed  together,  not  separately.  The 
malar  processes  or  bones  are  divided  in  the  usual  manner, 
the  nasal  processes  divided  with  a  chain-saw  passed  from 
one  orbit  to  the  other  through  the  lachrymal  bones,  and 
the  vomer  separated  with  cutting  forceps.  The  periosteum 
of  the  hard  palate  is  separated  from  the  gums  by  a  semi- 
circular incision  and  dissected  back,  the  posterior  connec- 
tions broken,  and  the  bone  removed  by  twisting  it  down- 
ward and  forward. 

PARTIAL     AND     TEMPORARY    EXCISION    OF    THE 

SUPERIOR  MAXILLA  TO   FACILITATE  THE 

REMOVAL  OF  NASOPHARYNGEAL 

POLYPS. 

Resection  of  Posterior  Portion  of  Hard  Palate  (  Xclaton). 
— The  soft  palate  is  first    divided    from    before    backward 

along  the  median  line,  and  the  incision  prolonged  forward 
through  the  periosteum  of  the  hard  palate  as  far  as  may 
be  judged  uecessary.  A  transverse  incision  is  next  made 
on  one  Bide  from  the  anterior  extremity  of  (he  first  toward 
the  teeth,  and  the  flap,  including  half  the  .-oft  palate,  dis- 
sected oil'  the  bone  from  the  median  line  outward.  The 
muCOUS  membrane  on  the  floor  of  the  corresponding  nos- 
tril i-  then  divided  close  to  the  septum,  the  bone  perforated 
at   the  anterior  corners  of  the  denuded  surface,  and  the 


EXCISION  OF  THE  StJPEMOR  MAXILLA. 


169 


separation  of  the  quadrilateral   piece  accomplished  with 
cutting  forceps. 

After  removal  of  the  polyp  the  soft  parts  are  replaced 
and  stitched  together.     The  bone  is  sometimes  reproduced. 

A  little  larger  opening  may  be  obtained  by  making  the 
transverse  incision  extend  from  one  side  of  the  hard  palate 

Fig.  64. 


Resection  of  hard  palate  to  expose  nasal  fossae.     A.   Nelaton's  operation.      B. 
Chatot's  operation. 

to  the  other,  and  then  chiseling  away  the  included  bone — 
in  other  words,  nearly  the  whole  of  the  bony  floor  of  the 
nasal  cavity  (Fig.  <!4,  .1).  At  the  close  of  the  operation 
staphylorrhaphy  is  performed. 

Osteoplastic  Resection   of  the   Anterior   Portion  of  the 
Palate  (Chalot,  Fig.  04,  B).     The  upper  lip  is  everted 


L70  EXCISION  OF  JOINTS  AND   BONES 

and  the  mucous  membrane  cut  in  the  line  of  it.-  reflection 
from  the  bicuspid  teeth  of  one  side  to  a  corresponding 
point  on  the  other — the  nasal  fossa  is  thus  entered,  the 
canine  teeth  are  extracted,  and  the  alveolus  and  hard 
palate  divided  on  each  side  by  the  chisel  and  knife.  The 
line  of  section  runs  through  the  canine  sockets  and  passes 
back  through  the  hard  palate  close  to  its  lateral  margins 
as  far  as  its  posterior  border.  The  vomer  is  then  sepa- 
rated, and  the  quadrilateral  piece  of  bone  thus  marked 
out  is  turned  down,  the  unsevered  attachments  of  the  soft 
palate  serving  as  a  hinge.  At  the  close  of  the  operation 
it  is  replaced  and  sutured  in  position. 

Resection  of  the  Upper  Portion,  Leaving  the  Hard  Palate 
and  Alveolar  Process  (Von  Langenbeck). — The  following 
is  somewhat  abridged  from  the  description  in  the  Deutsche 
Klinih,  1861,  page  283: 

An  incision  convex  downward  from  the  ala  of  the  nose 
to  the  malar  bone,  and  along  the  zygoma  backward.  A 
second  incision  from  the  nasal  process  of  the  frontal  along 
the  lower  border  of  the  orbit,  meeting  the  first  at  the 
middle  of  the  malar  bone  (Fig.  63,  L). 

The  knife  penetrates  to  the  bone  throughout.  The 
periosteum  and  overlying  soft  parts  are  only  separated 
sufficiently  to  permit  the  use  of  a  saw  or  chisel  along  the 
lines  thus  indicated.  But  the  periosteum  on  the  upper 
side  of  the  second  incision  is  detached  from  the  floor  of 
the  orbit  as  far  back  as  the  spheno-maxillary  fissure. 

Next  the  masseter  is  separated  from  the  exposed  por- 
tion ol*  the  malar  bone,  and  a  pointed  elevator  is  passed 
horizontally  below  the  zygomatic  arch  and  through  the 
pterygo-maxillary  fissure  to  the  outer  wall  of  the  nasal 
cavity.     It    is   recognized   here   by   a    linger    introduced 

through  the  mouth.  A  line  sawis  passed  in  this  line  ami 
made  to  eiil  through  tin'  zygoma  and  malar  bone  upward 
into  the  spheno-maxillary  fissure  :  it  then  follows  the  floor 

of  the  orbit  and  ends  just  shorl  of  the  lachrymal  bone; 
<»r  the  cut  may  be  made  with  a  chisel  from  before  back- 
ward. 

The   -;i\\   i-  then    reentered    into   the  pt erygo-ma x i  1  la py 


EXCISIOh    OF  THE  SUPERIOR   MAXILLA.         171 

fissure  at  the  outer  extremity  of  the  line  of  bony  division 
at  the  lower  border  of  the  malar  hone,  and,  passing-  through 
the  walls  of  the  antrum  very  nearly  in  the  line  of  the  lower 
cutaneous  incision,  enters  the  anterior  nares  elose  to  the 
nasal  floor.  An  elevator  is  now  passed  a  second  time  into 
the  pterygo-maxillary  fissure,  and  the  portion  of  the  supe- 
rior maxilla  which  has  been  separated  is  forced  up  till  the 
free  portion  of  the  malar  bone  is  brought  into  the  middle 
line  of  the  face.  The  attachments  of  this  fragment  con- 
sist of  the  nasal  bone  and  the  nasal  process  of  the  superior 
maxilla,  with  the  hitherto  undisturbed  periosteum  and  soft 
parts  at  the  base  of  the  original  tongue-shaped  incision. 

A  less  satisfactory  view  of  the  naso-pharyngeal  region 
is  obtained  if  the  floor  of  the  orbit  is  preserved.  The 
periosteum  on  the  upper  side  of  the  orbital  incision  is  not 
disturbed.  The  zygoma  is  cut  through  as  before  into  the 
spheno-maxillary  fissure.  A  chisel  is  driven  from  before 
backward  in  the  line  of  the  upper  cutaneous  incision 
through  the  anterior  and  outer  walls  of  the  antrum  just 
below  the  orbital  plate,  then  through  these  openings  the 
inner  wall  of  the  antrum  is  divided.  The  chisel  pene- 
trates to  the  spheno-maxillary  fossa.  The  lower  line  of 
bony  division  is  the  same  as  in  the  last  method  described, 
and  the  fragment  is  turned  over  in  the  same  manner. 

After  the  completion  of  the  operation  it  is  replaced  and 
maintained  in  position  by  sutures  or  pressure. 

Von  Langenbeck's  operation  is  difficult;  it  destroys 
the  orbicular  branches  of  the  facial  nerve,  often  damages 
the  lachrymal  duct,  and  gives  very  little  better  view  of 
the  nasal  cavity  than  Gucrin's  partial  extirpation  of  the 
superior  maxilla. 

OTHER  METHODS  OF  GAINING  ACCESS  TO  THE 
PHARYNX  THROUGH  THE  NOSE. 

These  may  here  be  described,  although  properly  speak- 
ing they  are  not  resections  of  the  superior  maxilla. 

Boeckel's  Operation.  (Fig.  61,  I>,  and  Fig.  63,  K.) — 
The  incision  begins  near  the  root  of  the  nose  slightly  to  one 
side  of  the  median  line.     It  passes  in  a  curved  direction 


172 


EXCISION  OF  JOINTS  AND   BONES. 


down  to  the  lower  free  border  of  the  nasal  bone;  from 
here  to  the  junction  of  the  ala  and  cheek  and  a  short  dis- 
tance outward  on  the  cheek.  The  second  incision  passes 
from  the  origin  of  the  first  at  the  root  of  the  nose  along 
the  edge  of  the  orbit  to  the  infra-orbital  foramen.  It 
must  clear  the.  lachrymal  sac.  This  tongue-shaped  flap  is 
raised  with  the  periosteum  and  exposes  a  triangular  sur- 
face of  bone.  After  retracting  the  soft  parts  a  chisel  is 
driven  through  the  superior  maxilla  so  as  to  divide  it 
vertically  just  inside  the  infra-orbital  foramen  between 
the  margin  of  the  orbit  and  the  upper  surface  of  the  hard 
palate.  The  chisel  should  be  obliquely  directed  and  enter 
the  nasal  cavity  near  the  vertical  plate  of  the  palate  bone. 


Fig.  65. 


Ollier's  operation  for  removal  ofa  aaso-pharyn&eal  polyp,     /•'.  Mi 
very  large  polyp. 


ilicatioi]  for  a 


The  nasal  process  of  the  superior  maxilla  and  the  nasal 
bone  are  cut  very  nearly  in  the  line  of  the  upper  cutaneous 

incision.  The  lachrymal  sac  must  be  spared.  The  bony 
division  is  carried  down  to  the  lower  free  border  of  the 
nasal  bone.  Finally  the  chisel  is  driven  into  the  nasal 
cavity  through  the  anterior  and  inner  walls  of  the  antrum 
on  a  line  reaching  from  the  lower  termination  of  the  first 
bony   incision   to  the  floor  of  (he  nose. 

The  inferior  and  middle  turbinated  bones  are  removed 

with    the    mass    thus   marked    out,  which    is    more    or    less 

pyramidal  in  shape  with  the  apex  toward  the  posterior 
oares. 


EXCISION   OF   THE   INFERIOR    MAXILLA.  173 

At  the  close  of  the  operation  the  periosteum  and  skin 
are  replaced  and  sutured  in  position. 

Oilier  turns  the  whole  nose  downward.  He  begins  his 
incision  at  the  edge  of  the  hone  close  behind  theala  of  the 
nose,  carries  it  upward  along  its  side  to  the  highest  part 
of  the  depression  between  the  eyes,  then  across  and  down 
to  the  corresponding  point  on  the  other  side  (Fig.  (V),  A). 
The  bone  is  sawn  through  in  the  line  of  the  incision,  the 
necessary  liberating  incisions  made  in  the  septum  or  the 
sides,  and  the  nose  turned  down. 

The  septum  is  pressed  aside,  the  polyp  extracted,  its 
base  of  implantation  scraped  and  the  nose  replaced. 

A  modification  which  is  sometimes  desirable  on  account 
of  the  size  of  the  polyp  or  the  distance  of  its  implantation 
is  indicated  in  Fig.  65,  B.  The  incision  runs  more  ob- 
liquely backward  and  a  transverse  one  is  made  from  each 
end  of  the  ala  of  the  nose.  The  bone  is  divided  in  the 
direction  of  the  cutaneous  incisions,  in  the  vertical  one  as 
before  described,  in  the  horizontal  one  by  passing  a  fine 
saw  across  the  nostrils  through  holes  made  between  the 
bone  and  cartilages  and  sawing  backward.  This  line 
of  section  must  be  high  enough  to  avoid  the  roots  of 
the  teeth. 

In  some  cases  it  is  sufficient  to  mobilize  the  lower  end 
of  the  nose  by  an  incision  under  the  lip  in  the  gingivo- 
labial  fold  and  then  by  carrying  it  and  the  lip  upward 
very  free  access  to  the  nasal  fossa?  is  obtained. 

Aint<iii<I(t/<','  after  turning  the  lip  and  nose  upward  in 
this  fashion,  saws  through  the  alveolus  and  hard  palate  in 
the  middle  line  close  to  one  side  of  the  vomer.  The  soft 
palate  may  also  be  split  if  more  space  is  required.  The 
saw  cut  can  then  be  made  half  an  inch  or  more  wide  by 
prying  apart  the  maxilla?.  This  affords  a  somewhat  lim- 
ited means  of  access  to  the  naso-pharyngeal  region. 

EXCISION  OF   THE  INFERIOR  MAXILLA. 

This  may  be  total  or  partial,  and   partial   excision   may 
involve  the  removal  of  any  part  of  the  body  of  the  bone 
•Lancet,  Jan.  5,  lss'.t. 


174  EXCISION  OF  JOINTS  AND  BONES. 

or  of  the  ascending  ramus.  Partial  excision  of  the  body- 
may  sometimes  be  accomplished  through  the  mouth  with- 
out the  aid  of  a  cutaneous  incision,  or  by  an  incision 
along  the  lower  border  of  the  bone  with  or  -without  an- 
other at  right  angles  to  it  extending  toward  or  even 
through  the  lip,  or  by  two  vertical  incisions  downward 
from  the  angles  of  the  mouth  when  only  the  upper  part 
of  the  body  of  the  bone  is  to  be  removed. 

When  the  ascending  ramus  also  is  to  be  resected  the  in- 
cision should  pass  along  the  lower  border  of  the  bone  to 
the  angle  of  the  jaw,  and  then  upward  along  the  posterior 
border  of  the  ramus  to  the  level  of  the  lobule  of  the  ear. 
If  the  incision  is  carried  higher  the  facial  nerve  is  neces- 
sarily divided  with  consequent  paralysis  of  the  muscles 
supplied  by  it,  a  complication  which  should  be  avoided. 
The  horizontal  portion  of  the  incision  should  be  a  little 
below  the  border  of  the  bone  in  order  that  the  cicatrix 
may  be  less  conspicuous.  Syme  removed  the  entire  ramus 
with  the  condyle,  without  opening  into  the  cavity  of  the 
mouth,  by  an  incision  slightly  convex  backward  extending 
from  the  zygoma  to,  and  a  little  beyond,  the  angle  of  the 
jaw. 

The  principal  danger  is  of  injury  to  the  internal  maxil- 
lary artery,  which  lies  almost  in  contact  with  the  inner 
side  of  the  neck  of  the  condyle.  The  lingual  nerve  also  is 
in  close  relation  with  the  inner  side  of  the  ramus,  lying 
between  it  and  the  internal  pterygoid  muscle.  Maisonneuve 
introduced  ;i  modification  of  the  method  of  operating  which 
has  rendered  it  almost  easy  and  has  diminished  the  above- 
mentioned  danger.  It  consists  in  separating  the  attach- 
ments of  the  condyle  by  twisting  and  tearing  out  the  bone 
alter  all  the  connect  ions  have  been  divided.  If  this  modi- 
fication, which  sounds,  perhaps,  rougher  and  less  surgical 
than  it  really  is,  is  not  adopted,  the  joint  must  he  ap- 
proached from  in  front  so  as  to  avoid  the  external  carotid, 

which    lies  close  behind    the    bone  in    the  substance  of  the 

parotid.     It   is  sometimes  allowable  to  divide  the  neck  of 

ilif  condyle,  or  even  the  ramus  below  the  sigmoid  notch, 
with  cutting-pliers,  and  Leave  the  tipper  fragment  in  place. 


EXCISION  OF  THE  INFERIOR   MAXILl  I.         L75 

Another  danger  is  in  the  division  of  the  attachments  of 
the  genio-hyo-glossus  muscles  to  the  bone.  The  tongue, 
deprived  of  its  support,  falls  back  upon  and  closes  the 
glottis.  As  a  preliminary,  therefore,  to  any  operation  in 
which  these  attachments  are  divided,  a  stout  ligature 
should  be  passed  through  the  tip  of  the  tongue  and  held  by 
an  assistant.  After  the  operation  it  should  be  fastened  to 
a  harelip  pin  in  the  external  incision,  or  to  the  skin  of  the 
face  by  a  strip  of  adhesive  plaster,  and  retained  for  a  couple 
of  days,  at  the  end  of  which  time  the  muscles  will  usually 
have  formed  new  attachments. 

The  bone  should  be  sawn  through  with  a  wire  or  com- 
mon saw,  according  to  circumstances,  or  merely  nicked 
with  the  saw,  and  its  division  completed  with  cutting- 
pliers.  The  tooth  occupying  the  proposed  line  of  section 
should  first  be  drawn. 

Ligature  of  one  or  both  carotids  has  been  performed  as 
a.  preliminary  operation  to  prevent  excessive  hemorrhage, 
but  it  has  proved  to  be  not  only  unnecessary,  but  inef- 
fectual. In  Mott's  case  the  main  operation  had  to  be  ad- 
journed to  allow  the  patient  to  recover  from  the  shock  of 
the  preliminary  one.  In  another  case  in  which  both  car- 
otids had  been  tied,  the  main  operation  had  to  be  aban- 
doned on  account  of  hemorrhage.1  Syme  says  the  pre- 
liminary ligation  is  unnecessary,  because  the  only  arteries 
that  need  to  be  divided  are  the  facial  and  the  transverse 
branches  of  the  temporal,  bleeding  from  which  can  be 
easily  controlled,  and,  furthermore,  all  the  advantages  of- 
fered by  ligation  of  the  carotids  can  be  obtained  by  their 
temporary  compression  during  the  operation. 

The  attempt  should  be  made,  when  possible,  to  get  pri- 
mary union  of  the  intra-buccal  wound  and  to  drain 
through  the  external  one.  This  makes  it  easier  to  keep 
the  wound  clean,  and  avoids  the  risks  incident  to  the 
swallowing  of  the  decomposing  discharges. 

The  results  of  the  operation  are  usually  very  good,  and 
the  deformity  less  than  might  be  expected.     Subperiosteal 

1  Mentioned  by  Syme  in  Contributions  to  the  Pathology  and  Practice 
of  Surgery,  Edinb.,  1848,  p.  19. 


176  EXCISION  OF  JOINTS  AND  BONES. 

excision  has  been  followed  by  reproduction  of  the  entire 
bone  with  condyles  and  (it  is  claimed)  diarthrodial  cartil- 
ages, and  even  when  the  periosteum  is  not  preserved  the 
cicatrix  becomes  very  firm  and  fibrous,  and  able  to  sup- 
port a  plate  with  artificial  teeth. 

Resection  of  the  Anterior  Portion  of  the  Body. — This 
may  be  done  by  means  of  a  vertical  incision  in  the  median 
line,  or  of  a  horizontal  one  below  the  free  border  of  the 
bone,  or  from  within  the  mouth  without  any  cutaneous 
incision. 

If  one  of  the  incisions  is  made,  the  external  and  internal 
surfaces  of  the  bone  are  cleared  through  it,  a  tooth  drawn 
at  each  of  the  proposed  points  of  section,  and  the  bone 
sawn  through. 

If  no  external  incision  is  made,  the  external  surface  of 
the  bone  is  cleared,  beginning  at  the  edge  of  the  gum  or  in 
the  gingivo-labial  fold,  according  as  the  periosteum  is  or 
is  not  to  be  preserved,  and  the  lip  drawn  down  under  the 
chin  so  that  the  bone  protrudes  through  the  mouth.  It 
can  then  be  easily  sawn  through  and  freed  from  its  attach- 
ments on  the  inner  side. 

Resection  of  the  Lateral  Portion  of  the  Body. — The  in- 
cision extends  along  the  lower  border  of  the  jaw  from  its 
angle  nearly  to  the  symphysis,  and  then  is  carried  ver- 
tically upward  to  the  base  of,  but  not  through,  the  lip. 
The  flap  is  dissected  up,  the  elevator  being  used,  of  course, 
if  the  periosteum  is  to  be  preserved,  the  inner  surface  of 
ile'  bone  cleared  near  the  symphysis  for  the  passage  of  a 
wire-saw,  and  the  section  made  if  possible  at  a  short  dis- 
tance from  the  median  line,  so  as  not  to  disturb  the  inser- 
tion of  the  gcnio-hyo-glossus.  This  section  may  be  made 
with  a  narrow  saw  from  before  backward  if  preferred. 

The  bone  is  then  drawn  downward  and  outward,  its 
inner  surface  cleared,  and  the  saw  applied  behind  the  last 
molar  tooth  or  at  any  suitable  point. 

Dr.    McBurney1    has    devised    a   remarkably    efficient 
mean-  of  maintaining  the  proper  relations  of  the  remain- 
ing  portions  to  each  other  until   repair  has  taken  place, 
1  Annals  of  Surgery,  L89 1. 


EXCISION  OF   THE   1S1ERI0R   MAXILLA. 


Ill 


and  of  thereby  avoiding  the  great  interference  with  func- 
tion which  formerly  ensued. 

Resection  of  the  Ramus  and  Half  of  the  Body.  (Fig. 
06.) — An  incision  is  begun  close  to  the  posterior  border 
of  the  ramus  on  a  level  with  the  lobule  of  the  ear,  carried 
down  to  the  angle  of  the  jaw,  and  thence  along  its  lower 
border  to  the  symphysis,  where  it  is  met,  if  necessary,  by 
a  vertical  one,  beginning  below  the  free  border  of  the  lip 
a  little  to  that  side  of  the  median  line  on  which  the  bone 

Fig.  66. 


Excision  of  iuferior  maxilla. 


is  to  be  removed.  The  flap  thus  marked  out  is  dissected 
up  from  the  bone  as  far  as  can  be  done  without  opening 
into  the  buccal  cavity,  and  the  divided  facial  artery  is 
tied.  The  inner  surface  of  the  bone  is  then  cleared  in  the 
same  manner,  an  incisor  tooth  drawn,  and  the  bone  sawn 
through. 

The  jaw  is  then  drawn  downward  and  forward,  the  de- 
nudation of  its  inner  surface  completed  by  dividing  the 
attachment  of  the  mucous  membrane  and  of  the  inter- 
nal pterygoid,  and  the  inferior  dental  nerve  cut  squarely 
across  at  the  point  where  it  enters  the  bone. 

The  insertion  of  the  temporal  muscle  upon  the  coro- 
noid  process  is  divided  with  curved  scissors  while  the  jaw 
12 


178  EXCISION   OF  JOINTS  AND  BONES. 

is  forcibly  depressed,  or  the  process  itself  is  cut  through 
if  it  is  so  loug  that  its  extremity  cannot  be  reached. 

The  remaining  soft  parts  are  carefully  detached  up- 
ward toward  the  condyle,  the  knife,  or  better,  the  ele- 
vator or  the  handle  of  the  scalpel,  being  kept  close  to  the 
bone  and  the  separation  completed  by  twisting  the  jaw  out. 

Excision  of  the  Whole  of  the  Inferior  Maxilla. — The  in- 
cision is  made  from  the  lobule  of  one  ear  down  to  the 
angle  of  the  jaw,  along  the  lower  border  of  the  bone  to 
the  other  angle  and  then  up  to  the  lobule  of  the  other  ear. 
The  outer  and  inner  surfaces  of  the  jaw  are  denuded,  the 
bone  sawn  through  in  the  median  line  and  each  half  re- 
moved as  before  described. 

In  the  subperiosteal  method  the  incisions  are  the  same, 
except  that  the  vertical  incision  may  be  in  the  median 
line,  since  the  genio-hyo-glossus  and  genio-hyoid  muscles 
remain  attached  to  the  periosteum.  The  attachment  of 
the  temporal  muscle  is  not  cut,  but  is  freed  with  the  ele- 
vator, as  is  also  that  of  the  external  pterygoid  to  the 
condyle 

Partial  Excisions  of  the  Inferior  Maxilla. — Removal  of  a 
portion  of  the  alveolar  process  is  often  necessary  in  the 
operation  for  epulis.  The  teeth  in  the  involved  segment 
are  drawn.  The  muco-periosteum  at  a  sufficient  distance 
from  the  growth  is  cut  through  and  the  bony  segment 
thus  marked  out  removed  through  the  mouth  with  a  chisel 
or  rongeur. 

If  a  portion  of  the  body  of  the  jaw  is  to  be  removed  it 
should  be  approached  by  an  incision  along  the  lower 
border  of  tic-  maxilla.  Whenever  possible  the  removal 
should  be  so  limited  as  not  wholly  to  destroy  the  contin- 
uity of  the  bone. 

The  part  represented  in  Fig.  <>1  is  the  ordinary  amount 
removed  for  epulis  ;  this  can  be  accomplished  through  the 
month. 

ANCHYLOSIS  OF  THE  JAW. 

The  mOSl  Common  cause  of  anchylosis  of  the  jaw  is 
found  in  cicatricial    retraction  or  adhesions  left  behind  by 


I  N(  HYLOSIS  OF  THE  J  A  W.  1 79 

intra-buccal  ulceration.  Kizzoli  (1858)  was  the  first  to 
point  out  that  the  proper  aim  of  an  operation  intended  to 
relieve  this  infirmity  should  be  the  establishment  of  a 
pseudarthrosia  in  front  of  the  adhesions  or  cicatricial 
bands  when  the  cause  itself  could  not  be  removed.  His 
operation  consisted  in  the  division  of  the  inferior  maxilla 
behind  the  last  molar  tooth  by  means  of  a  specially  con- 
structed osteotome  introduced  through  the  mouth.  Bony 
union  of  the  fracture  was  then  to  be  prevented  by  motion. 
Esmarch  (1859)  proposed  the  removal  of  a  wedge-shaped 
piece  of  the  bone.  By  some  surgeons  the  base  of  the 
wedge  is  taken  from  the  alveolar  process,  by  others  from 
the  lower  border  of  the  jaw.  Dieffenbach  proposed  to  di- 
vide the  ascending  ramus  horizontally  from  before  back- 
ward by  means  of  a  chisel  passed  through  the  mouth  to 
the  anterior  border  of  the  ramus. 

Operation  (removal  of  wedge-shaped  piece). — An  inci- 
sion is  begun  at  the  angle  of  the  jaw  and  carried  two 
inches  forward  along  the  lower  border.  A  narrow  strip 
of  bone  is  then  cleared  on  both  sides  up  to  the  edge  of  the 
gum,  just  anterior  to  the  masseter  and  in  front  of  the  con- 
tracted tissues,  a  tooth  drawn  if  necessary,  and  the  bone 
sawed  through.  The  anterior  fragment  is  then  depressed 
and  protruded  through  the  wound,  and  a  wedge-shaped 
piece  from  one-third  to  one-half  of  an  inch  in  width  at 
its  widest  part  cut  off  with  cutting  forceps.     (Fig.  61,  J.) 

Excision  of  the  Condyle. — This  may  be  required  for  the 
relief  of  anchylosis  due  to  bony  or  fibrous  union  between 
the  condyle  and  the  temporal  bone.  The  incision  is  be- 
gun at  the  lower  margin  of  the  zygoma  close  in  front  of 
the  temporal  artery  where  it  adjoins  the  ear  and  carried 
forward  along  the  zygoma  about  one  and  a-quarter  inches, 
the  tissues  being  divided  layer  by  layer  until  the  bone  is 
reached.  A  second  incision,  involving  only  the  skin,  is 
then  carried  from  the  center  of  the  first  directly  down- 
ward for  about  an  inch.  The  soft  parts  are  next  care- 
fully separated  with  knife  and  elevator  from  the  margin 
of  the  zygoma  and  the  outer  surface  of  the  joint  and 
drawn     downward    with     a    hook,    thus    preserving    the 


180  EXCISION  OF  JOINTS  AND  BONES. 

parotid,  nerves  and  vessels  from  injury.  The  neck  of 
the  condyle  is  then  freed  by  working  around  in  front  and 
behind  with  a  small  elevator,  keeping  close  to  the  bone, 
so  as  to  avoid  injury  to  the  internal  maxillary  artery  and 
finally  divided  with  the  chisel  and  rongeur.  If  there  is 
bony  union  between  the  condyle  and  temporal  bone  the 
chisel  must  be  again  used  to  separate  them,  its  edge  being 
kept  directed  somewhat  downward,  so  as  not  to  break 
through  into  the  cavity  of  the  cranium.  The  condyle  is 
then  grasped  with  forceps  and  twisted  out.  The  knife  or 
scissors  may  be  used  to  sever  any  remaining  connections, 
but  must  be  kept  close  to  the  bone. 

RESECTION  OF   THE   STERNUM. 

It  is  occasionally  necessary  to  remove  a  central  or  lat- 
eral portion  of  the  sternum  in  order  to  evacuate  pus  that 
has  formed  behind.  The  bone  is  exposed  by  a  longi- 
tudinal incision,  the  periosteum  detached  and  a  trephine 
applied,  or  if  the  bone  is  soft  the  opening  can  be  made 
with  a  gouge. 

RESECTION  OF  THE  RIBS. 

This  is  best  performed  in  those  regions  where  the  mus- 
cular layer  covering  the  bone  is  thin.  In  the  middle  third 
of  the  rib  the  intercostal  artery  lies  in  a  groove  on  the 
inner  side  of  the  lower  border. 

The  incision  should  correspond  in  length  and  direction 
with  the  portion  of  bone  to  be  removed,  and  may  be 
crossed  at  each  end  by  a  short  transverse  one.  The  Haps 
are  then  dissected  up,  the  periosteum  separated  as  far  as 
possible,  a  wire-saw  passed  at  the  limits  of  the  diseased 
portion,    and     the    piece    removed.      Instead    of  the    saw, 

cutting-pliers  may  be  used. 

In    EsUander's  operation  for  empyema  (thoraco-plastik), 

in  which  portions  of  several  adjoining  ribs  are  resected  to 
allow  the  chest  wall  to  sink  inward  and  unite  with  the  vis- 
ceral pleura,  the  position  of  the  incision  is  usually  deter- 
mined by  that  of  the  (istula.  The  incision  is  made  along 
the  intercostal  space  occupied  by  the  fistula,  and  the  ad- 


EXCISION  OF  THE  CLAVICLE.  181 

joining  ribs  dissected  as  above  described.  The  limits  of 
the  cavity  are  then  determined,  and  other  ribs  resected,  if 
necessary,  through  a  vertical  incision  made  from  the  center 
of  the  first,  If  the  costal  pleura  is  so  thick  as  to  prevent 
the  attainment  of  the  desired  object,  it  must  be  cut  away 
from  a  sufficient  part  of  the  area  of  resection.  From  three 
to  six  ribs  have  been  thus  resected,  in  lengths  varying  from 
one  to  three  inches.  The  operation  has  been  restricted  to 
the  ribs  between  the  third  and  eighth,  but  in  one  case  a 
small  portion  of  the  clavicle  also  was  removed.  Sometimes 
the  thickened  visceral  pleura  has  also  been  dissected  off. 

EXCISION  OF  THE  CLAVICLE. 

On  account  of  the  proximity  of  the  large  vessels  of  the 
neck  this  has  been  considered  the  most  dangerous  of  all 
the  excisions.  The  danger,  however,  varies  greatly  with 
the  nature  and  extent  of  the  disease  which  renders  the 
operation  necessary.  Thus,  when  there  is  osteitis  with 
thickening  and  loosening  of  the  periosteum,  the  operator 
can  easily  keep  close  to  the  bone,  and  the  danger  of  injury 
to  the  vessels,  as  well  as  of  exciting  diffuse  inflammation 
below  the  deep  fascia,  is  reduced  to  the  minimum.  On 
the  other  hand,  when  caries  has  existed  for  a  long  time, 
the  soft  parts  have  become  infiltrated  and  bound  down, 
and  the  bone  thickened  and  roughened,  the  difficulties  are 
immensely  increased ;  and  when  the  bone  is  the  seat  of  a 
malignant  tumor,  extending  in  all  directions,  its  removal 
may  tax  the  powers  of  the  most  skilful.  Valentine  Mott 
spoke  of  his  case  as  the  most  difficult  and  tedious  opera- 
tion he  had  ever  witnessed  or  performed  ;  it  lasted  four 
hours,  and  more  than  forty  ligatures  were  applied,  in- 
cluding two  upon  the  internal  jugular  vein. 

As  only  the  inner  half  of  the  bone  is  in  close  relation 
with  the  vessels,  and  the  danger  is  especially  great  at  the 
sterno-elavicular  joint,  it  is  advisable  first  to  raise  the 
outer  end  of  the  bone  from  its  place  by  opening  its  artic- 
ulation with  the  acromion  or  by  dividing  it  a  little  to  the 
inner  side  of  that  joint,  and  then,  after  clearing  the  pos- 
terior surface  from  without  inward,  to  divide  the  attach- 


182  EXCISION  OF  JOINTS  AND  HONES. 

nients  of  the  inner  end  while  twisting  the  bone  upward 
about  its  loog  axis,  and  keeping  the  edge  of  the  knife 
against  it.  When  this  is  impracticable  the  periosteum 
must  be  carefully  separated  near  the  middle,  and  the  bone 
sawn  through  with  the  usual  precautions  against  injury  to 
the  underlying  parts.  Each  half  is  then  raised  in  turn 
and  dissected  out. 

For  the  removal  of  a  tumor  no  fixed  rules  can  be  given. 
In  other  eases  the  directions  are  as  follows  : 

Operation. — The  subperiosteal  method  must  be  em- 
ployed throughout.  The  incision  is  made  along  the  ante- 
rior surface  of  the  bone,  and  corresponds  in  length  with  the 
portion  to  be  removed.  A  short  transverse  incision  is 
then  made  at  each  end  of  the  first,  the  flaps  dissected  up, 
and  the  denudation  carried  as  far  as  possible  around  the 
bone  above  and  below. 

The  bone  is  then  freed  at  its  acromial  end,  or  divided 
in  the  middle,  and  the  separation  completed  as  above  de- 
scribed. 

EXCISION  OF  THE   SCAPULA. 

It  is  impossible  to  lay  down  fixed  rules  for  making  the 
incision  when  the  operation  is  rendered  necessary  by  a 
tumor  of  the  bone.  They  will  be  determined  by  the  cir- 
cumstances of  the  case,  and  especially  by  the  extent  of  the 
disease,  for  while  in  some  cases  the  acromial  end  of  the 
clavicle  must  also  be  removed,  in  others  the  acromion  and 
neck  of  the  scapula  may  be  left  behind. 

Mr.  Holmes1  says:  "  The  surgeon  turns  down  appro- 
priate skin  flap-.  *  *  *  When  the  whole  tumor  is  thus 
exposed,  the  muscles  inserted  into  the  vertebral  border  of 

the  bone  should  be  rapidly  divided,  as  also  those  which 
are  attached  to  the  spine  of  the  scapula.  The  tumor 
should  lie  lifted  well  up  and  freed  from  its  other  attach- 
ments, commencing  from  its  lower  angle.  The  subscapu- 
lar artery  is  divided  Dear  the  end  of  the  operation,  and 
can  be  held  till  the  tumor  is  removed,  or  can  be  at  once 
tied.  The  Ligaments  of  the  shoulder  are  then  easily 
divided  and  the  mass  removed." 

'A  System  <>f  Surgery,  Vol.  V.,  p.  669. 


EXCISION  OF  THE  CLAVICLE.  183 

Gross1  made  a  vortical  incision  sixteen  inches  long 
downward  from  the  superior  angle  of  the  scapula,  and 
circumscribed  an  oval  portion  by  a  second  curved  inci- 
sion, beginning  five  inches  below  the  upper  end  of  the 
first  and  ending  about  the  same  distance  above  its  lower 
end,  and  removed  the  bone  after  sawing  through  the 
acromion  and  neck  of  the  scapula. 

Velpeau  2  recommends  three  incisions  :  one  along  the 
spine  of  the  scapula,  the  others  starting  from  the  ante- 
rior extremity  of  the  first  and  running,  one  toward  the 
root  of  the  neck,  the  other  toward  the  axilla  behind. 

Syme  made  two  incisions  crossing  each  other  near  the 
center  of  the  tumor.  Other  surgeons  have  made  triangular 
or  semilunar  flaps. 

In  January,  1878,  Dr.  George  A.  Peters  removed,  at  the 
New  York  Hospital,  the  entire  scapula  for  malignant  dis- 
ease, leaving  the  arm.  He  made  an  incision  along  the 
spine  of  the  scapula,  divided  the  fibers  of  the  deltoid  and 
trapezius,  and  exposed  the  tumor,  which  involved  only  the 
acromion  and  adjoining  portion  of  the  spine.  He  then 
made  a  vertical  incision  across  the  center  of  the  first, 
beginning;  two  inches  above  it  and  extending;  to  the  inferior 
angle  of  the  scapula,  reflected  the  flaps,  dissected  out  the 
under  surface  of  the  bone  from  behind  forward,  sepa- 
rated the  acromion  from  the  clavicle  and  humerus,  and 
then,  raising  the  lower  angle  of  the  scapula  toward  the 
head,  approached  the  coracoid  process  from  below,  and 
found  no  difficulty  in  separating  it  from  its  attachments. 
Only  two  vessels  required  ligation,  the  supra-scapular  and 
a  large  branch  of  the  subscapular.  The  result  was  very 
good ;  six  weeks  afterwards  the  wound  had  closed,  and 
the  patient  possessed  a  certain  degree  of  control  over  the 
humerus. 

Subperiosteal  Excision  of  the  Scapula  (Oilier).  (Fig.  67.) 
1.    IXCISIOX  OF  THE  SKIN  AND  MUSCTTLAB  INTERSTICES. 

— An  incision  is  made  along  the  whole  length  of  the  spine 
of  the  scapula,  and  from  its  posterior  extremity  two  others 

'Gross's  System  of  Surgery,  Vol.  II.,  p.  1078. 
2  Me'decine  Operatoire,  Vol.  II.,  p.  659. 


184 


EXCISION  OF  JOISTS  A XI)  BOXES. 


are  made,  one  following  the  posterior  border  clown  to  the 
interior  angle,  the  other  running  obliquely  forward  and 
upward  for  about  an  inch.  A  short  transverse  incision 
may  also  be  needed  at  the  anterior  end  of  the  first. 

•2.  Denudation  of  the  Boxe. — The  attachments  of 
the  deltoid  and  trapezius  to  the  acromion  and  spine  are 
separated,  the  periosteum  of  the  posterior  border  of  the 
scapula  divided  in  the  interstice  between  the  rhomboideus 
and  infra-spinatus,  and  the  infra-spinous  fossa  carefully 

Fig.  67. 


Excision  of  1 1 1  <  -  scapula. 

denuded.  The  periosteum  is  very  thin  in  its  lower  third. 
The  lower  angle  is  freed  by  detaching  the  teres  major  and 
serratus  magnus,  the  bone  raised,  and  the  subscapularis 
detached  from  below  upward.  If  the  marginal  cartilage 
ig  nol  completely  ossified  and  united  with  the  bone,  it 
should  be  separated  and  left  adherent  to  the  periosteum. 
The  BUpra-spinous  fossa  is  then  cleared,  care  being 
taken  not  to  injure  the  supra-scapular  nerve  in  the  supra- 
scapular notch,  but  to  raise  it  up  with  the  periosteum  and 
it-  fibroue  sheath.     The  posterior  part  of  the  bone  is  then 


UKSE0T10N  OF  THE  HUMERUS.  185 

carried  upward  and  forward  and  the  denudation  of  its 
under  surface  and  anterior  border  completed. 

If  the  extent  of  the  disease  permits,  the  denudation 
should  stop  at  the  neck  of  the  scapula,  which  is  then  di- 
vided with  a  chain-saw  or  cutting  forceps. 

3.  Opening  ok  the  Scapueo-humeral  Joint.  De- 
tach mkxt  OF  THE  AeTICULAE  CAPSULE  AND  DENUDA- 
TION of  the  Coeacoid  Peocess. — The  acromion  is  next 
separated  from  the  clavicle,  the  scapula  turned  upward, 
the  joint  opened  from  below,  and  as  the  bone  is  pressed 
steadily  upward  everything  that  holds  is  detached  with 
an  elevator.  After  the  coracoid  process  has  been  thus 
separated  from  most  of  its  muscular  and  ligamentary  at- 
tachments, the  few  that  remain  can  be  broken  by  twist- 
ing the  bone  away.  In  suitable  cases  the  coracoid  proc- 
ess may  be  divided  at  its  base  and  left  in  place,  and  thus 
the  most  difficult  and  laborious  part  of  the  operation  done 
away  with. 

The  partial  excisions  of  flic  scapula  do  not  require  de- 
tailed description.  The  acromion,  spine  and  posterior 
border  are  reached  by  straight  or  slightly  curved  incisions 
along  the  portion  to  be  removed.  A  crucial  or  \\  incision 
is  required  at  the  angles. 

RESECTION  OF  THE  HUMERUS. 

The  position  of  the  musculo-spiral  nerve  is  the  most  im- 
portant element  in  this  operation.  In  its  passage  around 
the  posterior  aspect  of  the  humerus  the  nerve  lies  close  to 
the  bone  within  the  sheath  of  the  triceps  muscle,  and 
leaves  the  latter  on  the  outer  side  of  the  arm  to  enter  that 
of  the  supinator  longus  at  its  origin.  In  approaching  the 
bone,  therefore,  on  the  outer  side  near  the  junction  of  the 
middle  and  lower  thirds,  the  operator  should  lay  bare  the 
outer  border  of  the  braehialis  anticus  and  follow  down 
within  its  sheath  to  the  bone. 

Upper  Portion. — Same  incision  as  in  Ollier's  method  of 
excision  of  the  shoulder  carried  further  down  along  the 
outer  edge  of  the  biceps.  The  cephalic  vein  must  be 
sought  for  and  drawn  aside.     Periosteum  and  capsule  di- 


186  EXCISION  OF  JOINTS  AND   BONES. 

vided,  ltinic  denuded  and  removed  as  in  excision  of  the 
shoulder-joint  (q.  /•.). 

Middle  Portion. — Incision  along  the  posterior  border  of 
the  deltoid  and  outer  edge  of  the  biceps.  Outer  border  of 
the  brachialis  anticus  laid  bare  and  followed  down  to  the 
bone.  Division  of  the  periosteum  and  denudation  of  the 
bone,  with  especial  care  for  the  safety  of  the  musculo- 
spiral  nerve. 

Oilier  prefers  to  seek  the  nerve  and  draw  it  aside.  He 
also  recommends  that  whenever  it  is  possible  to  leave  a 
portion  of  the  shaft  connecting  the  extremities  it  should 
be  done,  as  a  precaution  against  shortening  and  the  forma- 
tion of  a  pseudarthrosis.  If  this  is  not  possible  the  chain- 
saw  is  passed  at  two  points,  and  the  intermediate  piece 
removed. 

Lower  Portion. — Incision  on  outer  side  of  the  posterior 
aspect  of  the  arm,  between  the  triceps  and  supinator 
longus,  as  in  Ollier's  excision  of  the  elbow  (/j.  v.). 

Total  Excision. — Combination  of  incisions  for  upper  and 
lower  portions.  After  the  ends  have  been  denuded  of  peri- 
osteum the  middle  portion  can  be  cleared  by  pushing  one 
end  out  through  its  incision  and  peeling  the  periosteum  back 
like  the  finger  of  a  glove  until  the  middle  is  reached.  The 
bone  is  then  -awn  off,  and  the  other  half  removed  in  a 
similar  manner  through  the  other  incision. 

EXCISION  OF  THE  ULNA. 
Longitudinal  incision  along  the  posterior  aspect  of  the 
bone,  joined  at  its  upper  end  by  a  short  one  running  ob- 
liquely  upward  and  outward  between  the  triceps  and  anco- 
neus. The  triceps  is  drawn  to  the  inner  side,  and  the 
olecranon  Freed.     After  separation  of  the  periosteum  the 

bone  ig  Bawn  through  in  the  middle,  and  each  piece  is  dis- 
sected  out  in  turn. 

EXCISION   OF   THE   RADIUS   (OLLIER). 
An  incision  involving  the  skin  only  i-  made  from  the 

styloid  process  of  the  radius  along  the  outer  border  of  the 

forearm  to  the  radio-humeral  articulation.     The  fascia  is 


METACARPAL  BONKS  AND   PHALANGES.        187 

divided  and  the  posterior  border  of  the  supinator  longus 
found.  By  following  it  toward  the  wrist  the  knife  can  be 
kept  between  it  and  the  extensor  tendons  of  the  thumb, 
which  can  then  be  drawn  backward  and  saved  from  injury. 
By  following  it  upward  the  interstice  between  it  and  the 
extensores  carpi  radiales  is  found,  through  which  the  oper- 
ator penetrates  to  the  radius  now  covered  only  by  the 
supinator  brevis.  The  latter  muscle  is  then  divided  longi- 
tudinally and  the  periosteal  sheath  opened. 

The  periosteum  is  detached  laterally,  the  bone  sawn 
through  at  its  middle,  and  each  fragment  removed  sepa- 
rately. 

Partial  Excisions  of  the  Ulna  and  Radius. — The  incisions 
and  methods  are  the  same  as  those  above  described. 

EXCISION  OF  THE  METACARPAL  BONES  AND 
PHALANGES. 

The  metacarpal  bones  should  be  exposed  by  a  longitu- 
dinal incision  along  the  dorsum.  As  the  extensor  ten- 
dons cross  the  bones  obliquely  this  incision  should  in- 
volve only  the  skin  at  first,  the  tendon  is  then  drawn 
aside  and  the  incision  carried  down  to  and  through  the 
periosteum,  which  must  be  retained  when  possible.  It  is 
advisable  that  the  joints,  especially  the  metacarpopha- 
langeal, should  not  be  opened. 

The  bone  is  then  divided  in  the  middle  with  cutting- 
forceps  and  each  end  dissected  out,  or  the  gouge  alone 
may  be  used. 

The  after-treatment  is  important.  Extension  must  be 
made  upon  the  corresponding  finger  for  a  long  time  to 
keep  it  from  being  drawn  up  into  the  hand.  In  the  case 
of  the  metacarpal  bone  of  the  thumb  lateral  pressure  must 
also  be  made. 

For  resection  of  a  phalanx  the  incision  should  be  made 
on  the  side  of  the  finder  near  the  dorsum.  For  the  ter- 
minal  phalanx  the  incision  should  be  U-shaped,  the  arms 
passing  along  the  sides  of  the  phalanx,  the  curve  around 
its  end. 

Resection  of  the  different  portions  of  the  thumb,  even 


188  EXCISIOX  OF  JOINTS  AND  JWN8S. 

if  not  subperiosteal,  is  to  be  preferred  to  amputation,  but 
the  contrary  is  true  of  the  phalanges  of  the  other  fingers. 
Lateral  pressure,  by  means  of  splints  or  an  India-rub- 
ber glove  finger,  and  extension  by  weight  must  be  made 
to  insure  the  necessary  length  and  proper  shape  of  the 
member. 

RESECTION  OF  THE  BONES  OF  THE  PELVIS. 

Oilier'  reports  a  case  in  which  he  removed  the  as- 
cending ramus  of  the  ischium  and  most  of  the  pubis  for 
suppurative  osteo-arthritis  of  these  bones  and  the  pubic 
synchondrosis.  The  incision  was  about  four  inches  long 
and  extended  from  a  fistula  in  the  genito-crural  fold  up 
toward  the  pubis.  The  periosteum  was  detached,  the  as- 
cending ramus  of  the  ischium  removed  and  then  the  as- 
cending ramus,  body  and  part  of  the  horizontal  ramus  of 
the  pubis.  The  bone  that  wras  removed  was  eroded  and 
rarefied,  but  not  necrotic. 

EXCISION  OF  THE  COCCYX   (OLLIER). 

This  may  be  required  on  account  of  disease  of  the 
coccyx,  of  coccygodynia,  or  as  a  preliminary  to  operations 
upon  the  rectum. 

The  limits  of  the  bone  are  determined  by  the  finger  in 
the  rectum,  and  a  longitudinal  incision  made  through  the 
skin  and  fibrous  covering  of  the  bone,  from  a  quarter  of 
an  inch  above  its  upper  to  the  same  distance  below  its 
lower  end,  and  a  transverse  incision  made  at  the  upper 
end  of  the  first.  The  posterior  surface  of  the  bone  is 
then  denuded. 

The  sacro-coccygeal  articulation  having  been  opened  by 
this  denudation,  its  fibro-cartilage  is  divided,  and  the 
cornua  cleared.  An  elevator  is  then  passed  through  the 
joint  and  used  as  a  lever  to  force  out  the  coccyx,  peeling 
of]'  ;it  the  same  time  the  fibrous  covering  of  its  anterior 
surface. 

If  tin'  sacrum  is  also  diseased,  and  the  gouge  is  used 
upon  it,  it  must  be  remembered  that  the  sacral  canal  ex- 

1  Dela  R£g6n6ration  des  Ob,  VoL  II.,  |>.  180. 


RESECTION  OF  THE  SHAFT  OF  THE  TIBIA.      189 

tends  to  its  very  end,  and  is  there  formed  posteriorly  not 
of  bone,  but  of  fibrous  tissue. 

RESECTION  OF  THE  SHAFT  OF  THE  FEMUR. 

A  longitudinal  incision  is  made  on  the  outer  side  in  the 
groove  between  the  vastus  externus  and  biceps,  with  a 
transverse  liberating  incision  at  each  end.  Denudation  is 
carried  as  far  around  as  possible,  the  wire-saw  passed  at 
each  end  of  the  diseased  portion,  and  the  denudation  com- 
pleted as  the  piece  is  raised  from  its  bed. 

In  the  case  of  a  child  traction  should  be  made,  and 
the  limb  kept  at  the  same  length  as  the  other ;  in  the 
case  of  an  adult  the  fragments  should  be  brought  nearer 
together,  for  the  patient  is  older  and  his  power  of  regen- 
eration less ;  and,  in  many  cases,  it  is  better  to  bring  the 
fragments  into  contact.  Shortening  is  less  of  an  infirmity 
than  pseudarthrosis. 

RESECTION  OF  THE  SHAFT  OF  THE  TIBIA. 

If  the  entire  diaphysis  of  the  tibia  becomes  necrotic  it 
may  be  removed  subperiosteally  and  a  fairly  useful  limb 
obtained,  especially  in  children.  The  incision  is  made 
parallel  to  and  jnst  in  front  of  the  internal  border.  At 
the  upper  end  it  lies  behind  the  tendons  of  the  sartorius, 
gracilis,  and  semitendinosus ;  further  down  the  internal 
saphenous  nerve  is  recognized  and  drawn  to  one  side. 

The  periosteum  is  incised  on  this  line,  and  raised  with 
an  elevator  which  should  be  well  curved  to  get  around  the 
sharp  angles  of  the  bone.  When  the  denudation  has  been 
completed,  if  the  bone  is  not  already  detached,  the  elevator 
is  used  to  press  back  and  protect  the  soft  parts  behind, 
while  the  bone  is  chiseled  or  sawn  through  as  close  to  the 
dead  area  as  possible.  A  transverse  incision  through  the 
periosteum  at  this  point  will  save  undesirable  denudation 
of  adjoining  healthy  bone. 

The  operation  is  most  frequently  required  to  remove 
the  necrosed  fragments  which  may  result  from  osteomy- 
elitis. 

If  there  is  an   involucrum,  it  must  be  chiseled  away 


190  EXCISION  OF  JOINTS  AND  BONES. 

very  freely,  so  as  practically  to  abolish  the  center  cavity, 
and  the  sound  bone  at  each  end  must  be  freely  cut  away, 
st i  as  to  leave  a  surface  sloping'  easily  down  to  the  bottom 
(posterior  wall)  of  the  cavity.  The  object  of  this  free  re- 
moval of  bone  is  to  permit  the  soft  parts  to  come  every- 
where into  contact  with  the  bone  when  they  are  brought 
back  and  sutured  together  over  it.  No  anxiety  as  to  sub- 
sequent weakness  of  the  bone  need  be  felt,  for  the  new  for- 
mation of  bone  will  be  ample. 

If  it  is  necessary  to  reach  the  tibia  on  its  external  sur- 
face the  skin  incision  should  lie  a  little  to  the  outer  side  of 
the  crest.  The  periosteum  is  cut  into  close  to  the  anterior 
border  of  the  bone,  and  elevated  with  the  attached  tibialis 
anticus  muscle.  When  the  gap  after  a  compound  fracture 
involves  the  entire  thickness  of  a  portion  of  the  shaft,  a 
corresponding  length  must  be  removed  from  the  shaft  of 
the  fibula  to  seeure  good  apposition  of  the  parts.  The 
fibula  is  best  approached  at  some  distance  above  or  below 
the  site  of  the  tibial  injury,  as  thus  there  will  be  less 
danger  of  infecting  this  fresh  wound,  and  subsequent  im- 
mobility can  be  more  readily  secured. 

The  posterior  surface  of  the  tibia  is  best  approached 
around  its  internal  border.  At  the  upper  extremity  the 
incision  is  made  as  already  described  behind  the  sartorius, 
gracilis,  and  semitendinosus,  and  the  periosteum  elevated 
with  the  attached  popliteus  muscle. 

RESECTION  OF  THE  FIBULA. 
The  lower  portion  of  the  fibula  is  subcutaneous,  its  upper 
portion  is  covered  by  the  peroneal  muscles.  The  biceps  is 
attached  to  its  head,  and  the  external  popliteal  or  peroneal 
nerve,  after  following  the  posterior  border  of  the  tendon  of 
that  muscle,  wind-  around  the  outer  side  of  the  neck  of 
the  fibula,  and  divides  into  the  anterior  tibial  and  musculo- 
cutaneous, the  latter  of  which  soon  becomes  superficial. 
Sometimes  tin-  division  and  even  the  subsequenl  ones, takes 

place  a-  high  up  a-  the  head  of  the  fibula,  and  then  there 

i-  danger  of  dividing  some  of  the  branches  during  resection 
of  the   upper  extremity   of  the   bone,  unless  the  method 


RESECTION  OF  THE   FIBULA.  191 

indicated  by  Oilier  is  strictly  carried  out.  The  earlier 
authors  considered  the  division  of  this  nerve  unavoid- 
able. 

As  the  upper  tibio-fibular  articulation  communicates  in 
a  large  proportion  of  cases  with  that  of  the  knee,  it  should 
not  be  opened,  except  when  it  shares  in  the  disease.  The 
head  of  the  fibula  should  be  divided  or  gouged  out  in 
such  a  way  as  to  leave  this  articulation  covered  by  a  thin 
but  complete  plate  of  bone. 

Resection  of  the  Upper  Extremity  of  the  Fibula  (Oilier).1 
— A  longitudinal  incision  is  begun  an  inch  above  the 
head  of  the  fibula  at  the  posterior  border  of  the  tendon  of 
the  biceps,  and  carried  down  a  little  behind  the  bone  along 
the  interstice  between  the  soleus  and  the  peroneal  muscles. 
The  incision  should  involve  only  the  skin  and  fascia. 

The  nerve  is  then  sought  for  where  it  passes  around 
the  neck  of  the  fibula,  and  protected  by  two  blunt  hooks 
placed  about  an  inch  apart.  While  thus  protected,  it  is 
freed  from  the  cellular  tissue,  which  binds  it  to  the  bone, 
and  then  drawn  forward  so  as  to  permit  the  division  of 
the  periosteum.  This  division  is  made  on  the  posterior 
border  of  the  bone,  and  carried  downward  as  far  as  is 
necessary  in  the  interstice  between  the  soleus  and  pero- 
neal muscles. 

The  periosteum  is  then  detached  and  the  bone  re- 
moved, either  by  dividing  it  at  two  points  with  a  wire- 
saw  or  chisel  and  removing  the  intermediate  portion,  or 
by  dividing  it  at  the  lower  limit  of  the  disease,  and  twist- 
ing out  the  upper  fragment,  or  by  modifying  the  latter 
method  to  the  extent  of  dividing  the  head  of  the  bone 
with  a  sharp  chisel  in  such  a  manner  as  to  leave  the 
tibio-fibular  joint  unopened. 

Resection  of  the  Lower  Portion  of  the  Fibula. — Longi- 
tudinal  incision  along  the  antero-external  aspect  of  the 
bone.  Denudation  and  removal  of  the  bone  in  the  usual 
manner.  For  other  details,  see  excision  of  the  ankle- 
joint. 

1  Traite  de  In  lJegencration  des  Os,  p.  267. 


192 


EXCISION  OF  JOINTS  AND  BONES. 


EXCISION  OF  THE  WHOLE  FIBULA. 

As  the  incisions  for  the  resection  of  the  upper  and  lower 
portions  lie  on  opposite  sides  of  the  peroneal  muscles,  they 
cannot  be  made  continuous  with  each  other.  Each  half  of 
the  bone  must  be  removed  separately. 


Fig.  68. 


EXCISION  OF  THE  BONES  OF  THE  FOOT. 

Calcaneum. — Disease  in  the  calcaneum  is  usually  cen- 
tral, leaving  a  sequestrum  inclosed  in  a  shell  of  rarefied 
vascular  bone,  or  a  cavity  is  formed  within  a  similar  shell 

by  ulceration  and  discharge 
through  one  or  more  fistulse. 
The  removal  of  the  entire  thick- 
ness of  the  bone  has  heretofore 
givcu  better  results  than  simple 
gouging  out  of  the  diseased  por- 
tions, ividemeni  de  I'os,  but  the 
anterior  portion  should  if  pos- 
sible be  left. 

Subperiosteal  Method 
(Oilier).  (Fig.  68,  A.)— An  in- 
cision involving  only  the  skin  is 
begun  at  the  outer  border  of  the 
tendo  Achillis  about  an  inch 
higher  than  the  tip  of  the  ex- 
ternal malleolus,  carried  down 
below  the  outer  tuberosity  of  the 
calcaneum  and  then  forward  and 
slightly  upward  to  the  upper  part 
of  the  base  of  the  fifth  metatarsal.  The  edge  of  the  tendo 
Achillis  and  the  upper  border  of  the  plantar  muscles  being 
recognized,  the  incision  is  carried  down  to  the  bone,  care 
being  taken  not  to  cut  the  peroneal  tendons. 

The  posterior  half  of  the  bone  is  then  denuded  with  an 

elevator,  and  the  tendo  Achillis  detached  and  pressed  to 

tin-  inner  side.  The  under  surface  and  posterior  third  of 
the  inner  aurface  are  next  cleared,  the  peroneal  tendons 
drawn  aside  with    blunt    hooks,  the   external    lateral    liga- 


.1.  Excision  of  the  calcaneum.    />'. 
Excision  of  i  In-  asl  ragalus, 


EXCISION  OF  THE  BONES  OF  THE  FOOT.       193 

ment  detached,  the  anterior  portion  of  the  outer  surface 
denuded,  and  the  caleaneo-cuboid  joint  opened. 

The  interosseous  ligament  is  divided  with  a  narrow  bis- 
tonrv,  the  bone  grasped  with  lion-forceps  and  turned 
downward  so  as  to  open  the  calcaneo-astragaloid  joints 
and  give  access  to  the  calcaneo-scaphoid  and  internal 
lateral  ligaments  and  to  the  inner  surface  of  the  bone. 

Resection  of  the  posterior  portion  alone  can  be  accom- 
plished much  more  expeditiously.  The  portion  to  be  re- 
moved is  denuded  and  then  sawn  off,  either  directly  or  by 
perforating  the  bone  and  sawing  it  from  above  downward 
with  a  chain-saw. 


Fig.  69. 


c-H 


A.  Excision  of  astragalus.    (Vogt.)    B.  Excision  of  ankle.    C.  Excision  of  calcis. 
(Farabeuf.) 

Farabeufs  Modification.  (Fig.  69,  C.) — The  incision 
begins  opposite  the  base  of  the  fifth  metatarsal  bone  exter- 
nally, and  is  carried  horizontally  backward  just  above  the 
margin  of  the  sole.  It  passes  on  the  same  level  around 
the  back  of  the  heel  and  is  prolonged  forward  about  an 
inch  on  its  internal  aspect.  A  second  incision  extends 
from  this  about  two  inches  vertically  upward  beside  the 
external  border  of  the  tendo  Achillis.  These  incisions 
involve  the  skin  only.  The  vertical  cut  is  now  deepened 
and  the  periosteum  divided  in  this  line,  taking  care  not  to 
damage  the  peroneal  tendons  which  lie  just  anteriorly. 
13 


194  I<:x<  ISIOX  OF  JOINTS  AND  BONES. 

The  periosteum  with  the  associated  ligaments  is  elevated 
first  on  the  outer  surface,  aided  by  deepening  the  hori- 
zontal incision  in  this  part  down  to  the  bone.  The  attach- 
ment of  the  tendo  Achillis  is  cut  and  the  posterior  aspect 
cleared  as  far  as  possible. 

The  periosteum  of  the  anterior  end  is  next  separated 
together  with  its  attached  ligaments,  and  afterward  the 
plantar  area  is  denuded.  The  anterior  extremity  is  grasped 
with  forceps  and  twisted  outward,  while  the  remaining 
attachments  are  severed  with  the  knife,  which  must  be 
kept  close  to  the  bone.  The  superior  surface  is  reached 
through  the  outer  incision  and  the  interosseous  ligament 
cut.  By  careful  work  with  the  elevator  the  internal  sur- 
face is  freed  from  the  periosteum  and  attached  ligaments 
and  the  bone  finally  removed  without  damage  to  the  ves- 
sels and  nerves  on  its  inner  side. 

Astragalus. — Excision  of  the  astragalus  may  be  rendered 
necessary  by  dislocation,  fracture,  or  tuberculosis,  or  it  may 
be  made  as  a  preliminary  step  in  excision  of  the  ankle. 

Operation  (Oilier).  (Fig-  68,  B.) — Curved  incision 
across  the  dorsum  of  the  foot,  with  convexity  directed 
forward  beginning  on  the  inner  side  at  the  point  where  the 
tendon  of  the  tibialis  anticus  crosses  the  tibio-tarsal  articu- 
lation, running  forward  and  outward  to  the  middle  of  the 
scaphoid,  and  then  backward  to  a  point  a  little  below  the 
tip  of  the  external  malleolus.  This  incision  must  expose 
but  not  involve  the  tendons. 

The  extensor  tendons  are  lifted  out  of  their  sheaths  and 
drawn  aside,  the  extensor  brevis  cut  across  or  detached  at 
its  origin,  and  the  neck  and  outer  non-articular  surface  of 
the  astragalus  cleared.  The  capsular  and  ligamentary  at- 
tachments of  the  bone  to  the  scaphoid  and  tibia  arc  sepa- 
rated, the  interosseous  ligamenl  divided,  and  the  foot  being 
turned  inward  the  insertion  of  the  strong  internal  tibio- 
astragaloid  ligamenl  is  detached.  The  remaining  connec- 
tions are  then  ruptured  by  grasping  the  bone  with  strong 
forceps  and  twisting  it  out. 

The  operation  is  made  easier  by  cutting  through  the 
neck  of  the  bone  and  first  removing  the  head. 


OPERATIONS   UPON  CRANIUM— TREPHINING.     195 

See  also  Vogt's  excision  of  the  ankle,  p.  1")7. 

When  dislocated  the  astragalus  may  be  easily  removed 
by  a  straight,  curved,  or  crucial  incision  made  over  the 
most  prominent  part,  and  avoiding  vessels,  nerves,  and 
tendons. 

When  badly  shattered,  as  in  gunshot  injury,  the  frag- 
ments may  be  removed  through  a  longitudinal  incision 
between  the  extensor  tendons  of  the  first  and  second  toes. 

For  simultaneous  removal  of  the  calcaneum  and  astrag- 
alus see  Osteoplastic  excision  of  the  foot,  p.  15<S. 

Metatarsal  Bones  and  Phalanges. — A  metatarsal  bone 
should  be  exposed  by  an  incision  along  the  dorsum  in- 
volving only  the  skin  ;  the  tendon  is  then  drawn  aside,  the 
periosteum  divided,  the  bone  denuded,  sawn  through,  and 
removed.  Whenever  possible,  the  upper  extremity  of  the 
bone  should  be  left. 

For  the  first  and  fifth  metatarsals  it  is  better  to  make 
the  incision  more  upon  the  side  than  upon  the  dorsum. 

If  the  corresponding  toe  is  to  be  preserved,  extension 
must  be  made  upon  it  for  a  long  time,  in  the  manner  and 
for  the  reasons  mentioned  under  excision  of  the  meta- 
earpal  bones. 

The  phalanges  and  their  articulations  are  best  excised 
by  lateral  incisions. 

OPERATIONS  UPON  THE  CRANIUM— TREPHINING. 

Although  the  term  trephining,  in  its  narrower  sense,  im- 
plies the  use  of  the  trephine,  yet  it  is  also  employed  to  in- 
dicate the  making  of  an  opening  in  the  skull  by  the  use 
of  other  instruments,  such  as  the  saw  and  chisel.  As  such 
openings  are  made  in  different  ways  and  with  different 
purposes,  it  will  facilitate  reference  and  avoid  repetition 
first  to  describe  the  methods  of  using  the  instruments  to 
make  the  opening. 

As  a  rule,  rarely  to  be  disregarded,  the  scalp  should  be 
widely  shaved  about  the  area  of  operation,  and  in  all  the 
more  extensive  operations  it  should  be  shaved  throughout 
in  order  the  better  to  maintain  asepsis. 

Trephine. — The  incision  may  be  straight,  curved,  or  []- 


196  EXCISION  OF  JOINTS  AND  BONES. 

shaped.  It  sometimes  becomes  desirable  to  make  a 
straight  incision  crucial,  but  this  form  is  generally  to 
be  avoided  because  of  probable  retraction  and  consequent 
delay  in  healing.  As  the  scalp  is  very  vascular  it  is  only 
when  a  well-rounded  flap  is  made  that  it  is  necessary  to 
take  account  of  the  position  and  direction  of  the  arterial 
trunks  with  a  view  to  avoid  sloughing. 

The  incision  should  be  made  freely,  the  knife  passing 
nearly  or  quite  to  the  bone  at  the  first  stroke,  in  order  that 
the  vessels  may  be  the  more  readily  secured.  After  the 
hemorrhage  has  been  arrested  the  pericranium  is  detached 
from  the  portion  of  bone  to  be  removed,  and  the  center- 
pin  of  the  trephine  (protruding  Jg  inch  and  firmly  clamped) 
is  forced  by  to-and-fro  rotatory  movements  into  the 
bone  at  the  place  selected,  and  these  movements  continued 
until  the  circular  edge  of  the  trephine  has  cut  a  groove 
sufficiently  deep  to  insure  its  steadiness  without  the  aid  of 
the  pin,  which  must  then  be  withdrawn,  so  as  to  avoid 
injury  by  it  to  the  dura  mater.  The  rotatory  movements 
are  continued  very  cautiously,  and  all  parts  of  the  groove 
frequently  examined  with  a  probe,  as  its  depth  increases, 
so  as  to  have  timely  notice  of  complete  perforation. 

The  teeth  of  the  trephine  should  be  freed  from  dust 
from  time  to  time  by  dipping  the  instrument  into  water. 
If,  as  is  usually  the  case,  perforation  takes  place  upon  one 
side  of  the  groove  before  it  does  upon  the  other,  the  tre- 
phine must  lie  slightly  inclined  so  as  to  act  only  upon  the 
unsawn  portion;  and  when  it  is  thought  that  the  perfora- 
tion is  complete  throughout  the  greater  part  of  the  circle 
the  remainder  may  be  broken  by  sharply  inclining  the 
trephine  or  with  a  thin-bladed  elevator. 

Chisel. — The  chisel  is  employed  only  in  cutting  bone- 
flaps  of  large  size,  to  he  temporarily  turned  back  and  then 
replaced,  mid  in  craniectomy,  and  in  widening  fissures  of 
;i  compound  fracture  for  their  better  cleansing.  There  is 
Borne  reason  to  think  that  jarring  of  the  brain  by  the  strokes 
of  the  mallet  may  be  prejudicial,  and  therefore  the  chisel 
should  be  held  very  obliquely  in  order  to  diminish  this 
effeel  of  I  he  blows.     Shallow  and  triangular  gouges  are  con- 


OPERATIONS  UPON  CRANIUM— TREPHINING.     197 

venient,  and  it  is  well  to  use  a  narrower  one  to  deepen  and 
complete  the  groove,  and  after  the  bone  has  been  wholly 
cut  through  at  one  point  to  pass  a  thin  periosteum  elevator 
between  the  bone  and  the  dura  beneath  the  adjoining  por- 
tion of  the  groove  as  it  is  deepened  in  order  to  protect  the 
dura  from  accidental  injury. 

Gigli  Wire-saw. — This  is  employed  for  long,  straight  in- 
cisions, or  to  circumscribe  large  bone-flaps  that  are  to  be 


Fio.  70. 


oigli  wire-saw. 

replaced.  The  instrument  (Fig.  70),  is  a  slender  rough- 
ened steel  wire,  and  is  used  like  a  chain  saw.  Openings 
in  the  bone  are  made  with  a  small  trephine  or  drill  at 
points  in  the  line  of  the  proposed  incision,  from  one  to  two 
inches  apart,  the  dura  mater  between  them  detached  with  a 
narrow,  sharply  curved  elevator,  the  wire  passed  from  one 
to  the  other,  and  the  bone  sawn  from  within  outward  by 
to-and-fro  movements  of  the  wire. 

Hemorrhage  from    the  diploe    is    checked   by   simple 


198  EXCISION  OF  JOINTS  AND  BONES. 

sponge  pressure  or  by  plugging  the  larger  vessels  with 
decalcified  bone  or  catgut.  If  the  purpose  of  the  opera- 
tion requires  the  brain  to  be  exposed,  the  dura  mater  is 
cut  about  one-quarter  of  an  inch  within  the  margin  of 
the  opening  and  turned  back  as  a  flap  ;  vessels  of  note- 
worthy size  can  be  secured  by  passing  a  small  curved 
needle  under  them. 

Hemorrhage  from  the  pia  or  brain  is  checked  by  sponge 
or  gauze  pressure.  If  this  fails  the  vessels  are  clamped 
and  tied  with  fine  catgut  ligatures.  The  Paquelin  cautery 
may  be  used  as  a  last  resort.  The  brain  can  be  punctured 
cautiously  with  a  probe  or  hypodermic  needle,  but  all 
lateral  movements  should  be  avoided. 

If  the  brain  lias  to  be  incised  pass  the  knife  through 
the  summit  of  a  convolution,  rather  than  in  a  sulcus,  as 
the  hemorrhage  is  less.  A  clot  can  be  wiped  out  with  fine 
sponges  or  picked  out  with  forceps.  An  encapsulated 
tumor  is  enucleated  with  curved  blunt-pointed  scissors, 
aided  by  the  finger.  But  one  that  infiltrates  the  brain 
must  be  cut  out  with  the  knife.  The  use  of  the  sharp 
spoon  is  not  allowable  in  this  situation. 

A  superficial  cyst  is  cither  enucleated,  or,  after  cutting 
off  its  superficial  surface,  it  is  simply  packed  and  drained. 
A  deeper  cyst  is  evacuated  and  packed,  or  continuous 
drainage  maintained  by  a  strip  of  rubber  tissue.  A  cav- 
itv  remaining  after  the  removal  of  a  cyst  or  tumor  is 
packed  with  gauze,  which  is  removed  gradually  to  pre- 
vent the  space  filling  with  a  blood  clot. 

Hemorrhage  from  a  sinus  or  large  vein  can  usually  be 
checked  by  gauze  pressure;  if  this  fail,  artery  clamps  can 
In-  applied  and  left  in  the  dressings  for  a  day  or  two.  At 
the  close  of  the  operation  a  folded  strip  of  rubber  tissue  is 
passed  :i-  :i  drain  beneath  the  dura,  which  is  stitched  with 
catgut  except  at  this  point  and  brought  out  of  the  lower 
angle  of  the  -kin  wound.  Often  the  drain  is  unnecessary 
and  the  wound-  in  the  dura  and  skin  may  be  closed  up 
tight,  the  former  with  catgut,  the  latter  with  silk  and 
dressed  aseptically. 

[f  the  attempt  is    to  be   made  to   replace  the   button   of 


OPERATIONS   UPON  CRANIUM— TBEPHINING.     199 

hone  removed  by  the  trephine,  it  must  be  kept  in  warm 
salt-solution  and  then  replaced  between  the  dura  and 
pericranium.  Thin  plates  of  various  metals  or  celluloid 
have  been  used  instead  of  bone  and  have  given  good  re- 
sults. The  benefit  seems  to  come  mainly  from  increased 
production  of  fibrous  tissue  in  the  opening.  It  is  claimed 
that  the  lining  membrane  of  an  egg  gives  a  similar  result. 

Temporary  Resection  of  the  Skull  by  Omega  Flap. — (For 
exploration,  removal  of  tumor,  or  excision  of  Gasserian 
ganglion.)  The  incision  takes  the  form  of  a  Greek  &, 
with  base  downward  to  secure  the  best  nutrition  to  the 
flap.  Everything  is  divided  down  to  the  pericranium. 
The  horizontal  feet  of  the  loop  are  each  about  half  an 
inch  long  and  separated  from  each  other  across  the  base 
by  at  least  an  inch  of  sound  skin.  The  width  of  this 
pedicle  should  be  about  half  that  of  the  flap.  The  hori- 
zontal cuts  serve  as  liberating  incisions  to  facilitate  the 
turning  back  of  the  flap  with  its  attached  bone.  The  di- 
mensions of  the  loop  vary  to  suit  the  requirements  of 
each  case,  but,  as  used  by  Wagner,1  they  are  as  follows  : 
Vertical  length,  6.5  cm.;  greatest  breadth,  5  cm.;  with  a 
pedicle  of  undivided  sound  tissue,  3  cm.  wide. 

After  the  soft  parts  have  retracted  the  periosteum  is 
cut  close  up  and  parallel  to  the  inner  edge  of  the  flap  and 
its  horizontal  continuations  below,  and  the  bone  cut  through 
along  the  entire  curved  portion.  When  this  cut  is  made 
with  the  wire  saw  it  should  be  so  inclined  that  the  outer 
surface  of  the  bone  flap  is  larger  than  the  inner,  in  order 
that  the  flap  when  replaced  shall  not  sink  below  its  former 
level.  A  periosteal  elevator  is  cautiously  pushed  in  as  a 
lever  at  the  top  of  the  curve  and  the  bone  flap  snapped  at 
its  base  by  a  sudden  quick  application  of  force  and  laid 
back  without  disturbing  the  attached  parts.  It  may  be 
necessary  to  aid  this  breaking  by  chiseling  the  outer  table 
from  either  or  both  angles  part  way  across  the  bone.  The 
skin  flap  overlaps  the  line  of  bony  division  about  one- 
quarter  to  one-half  an  inch,  and  is  united  by  interrupted 
silk  sutures,  with  or  without  drainage  in  the  lower  angle 
of  the  wound. 

1  Centralblatt  f .  Chir.,  1889,  p.  833. 


200  EXCISION  OF  JOINTS  AND  BONES. 

The  horizontal  "feet"  of  the  .(?  may  generally  be  dis- 
pensed with.  Their  only  nse  is  as  liberating  skin  in- 
cisions to  facilitate  the  turning  down  of  the  flap.  If 
needed  they  can  be  made  after  the  section  of  the  bone. 

Craniectomy  (Lannelongue).  —  An  incision  parallel  to 
and  a  ringer-breadth  to  one  side  of  the  longitudinal  sinus 
is  made  from  the  lambdoid  to  the  coronal  suture,  and  the 
bone  cut  along  the  corresponding  line  with  chisel,  ron- 
geur, or  wire-saw.  This  has  sometimes  been  extended  to 
reach  from  the  frontal  eminence  nearly  to  the  transverse 
sinus. 

A  similar  cut  has  occasionally  been  made  at  the  same 
time  on  the  opposite  side  of  the  head,  and  Lannelongue 
has  performed  the  operation  in  the  transverse  diameter  of 
the  skull,  the  incision  corresponding  nearly  to  the  coronal 
suture.  A  flap,  concavity  downward,  is  sometimes  fash- 
ioned, so  as  to  prevent  the  lines  of  skin  and  bone  division 
from  coinciding. 

Trephining  in  Fracture  of  the  Skull. — The  purpose  of  the 
operation  is  to  raise  depressed  portions  of  bone  and  to  dis- 
infect the  wound  when  the  fracture  is  compound.  After 
picking  out  the  loose  pieces,  depressed  but  still  attached 
pieces  can  be  forced  back  into  place  by  an  elevator  passed 
beneath  them  ;  if  there  are  no  loose  pieces  the  corner  of  a 
chisel  should  be  worked  into  one  of  the  cracks  at  the  edge 
of  the  depression  and  the  piece  gently  loosened  or  removed 
piecemeal  until  a  snlricient  opening  is  made  for  the  intro- 
duction of  an  elevator.  This  is  better  than  applying  a 
trephine  beside  the  depressed  area  for  it  involves  less  loss 
of  bone. 

The  Relation  of  the  Brain  to  the  Overlying  Parts. 
REID'S  METHOD.1 — The  "base  line"  is  drawn  through 
the  lowest  part  of  the  infra-orbital  margin  and  the  center 
of  the  external  auditory  meatus. 

Tin  great  /oiir/ihnl i  ad  I  fissure  is  marked  by  a  line  run- 
ning in  the  middle  line  of  the  skull  from  the  glabella  to 
tin-  external  occipital  protuberance. 

Tfu   transverse  fissure,  or  the  fissure  of  Bichat,  by  one 

1  Lancet,  September  27,  1884. 


OPERATIONS   UPON  CRANIUM— TREPHINING.    201 

from  the  external  occipital  protuberance  through  the 
auditory  meati. 

The  Si// r  in  a  fissure  starts  one  and  one-quarter  inches 
horizontally  behind  the  external  angular  process  of  the 
frontal  bone,  and  extends  to  a  point  three-quarters  of  an 
inch  below  the  most  prominent  part  of  the  parietal 
eminence. 

The  ascending  lineof  this  fissure  starts  at  a  point  in  this 


I'..  Fissure  of  Bichat,  e.  n.p.  External  angular  process  of  frontal  bone.  Sy.  a. 
fit.  Ascending  limb  of  Sylvian  fissure.  +.  Parietal  eminence.  F,  G,  D,  H,  E. 
Perpendiculars  to  base  line  locating  the  fissure  of  Rolando  (F.  EL),  p.  o.fis.  Parieto- 
occipital fissure.  I.  Jr.  f.  First  frontal  fissure.  2.  Jr.  J.  Second  frontal  fissure,  ase. 
Jr.  run.  Ascending  frontal  convolution,  i.  pur.  f.  Intra-parietal  fissure,  s.  m.  c. 
Supra-marginal  convolution,  ling.  <).  Angular  gyrus.  1.  /.  s.  c.  First  temporo- 
sphenoidal  convolution.  _'.  /.  s.  e.  Second  tcruporo-sphenoidal  convolution.  3.  t.  s. 
e.  Third  temporo-sphenoidal  convolution,  l.tt.f.  First  temporo-sphenoidal  fis- 
sure.   1.  U  &.J.  Second  temporo-sphenoidal  fissure.     (Starr.) 

line  two  inches  behind  the  external  angular  process,  and 
ascends  vertically  about  one  inch. 

Fissure  of  Rolando. — Draw  a  perpendicular  to  the  base 
line  starting  in  the  depression  in  front  of  the  external 
auditory  meatus,  and  another  perpendicular  to  the  base 
line  starting  from  the  posterior  border  of  the  mastoid  proc- 
ess at  its  root.  The  fissure  of  Rolando  is  indicated  by  a 
line  drawn  from  the  intersection  of  this  second  line  with 


202 


i:x<isioy  of  joists  and  bones. 


the  line  marking  the  great  longitudinal  fissure,  to  the  point 
of  intersection  of  the  anterior  perpendicular  with  the  hori- 
zontal limb  of  the  fissure  of  Sylvius  already  laid  out.  A 
simpler  way  of  indicating  the  Bolandic  fissure  is  to  draw 
a  line  three  and  three-eighths  inches  long  at  an  angle  of 
67°  with  the  sagittal  meridian  of  the  head,  from  a  point 
which  lies  back  of  the  glabella  in  this  meridian  55.7  per 
cent,  of  the  distance  from  the  glabella  to  the  inion. 
Cheyne's  method  of  measuring  this  angle  is  to  halve  a 


Showing  the  location  of  the  centers  on  the  cortes  of  the  lira  in.     (Stahr.) 

right  angle  by  doubling  a  square  piece  of  paper  into  a  tri- 
angle, and  then  halve  tli<'  45°  thus  obtained  by  folding 
one  of  lb'1  triangles.  By  unfolding  the  crease  first  made, 
leasing  the  lasl  unchanged,  there  results  the  sum  of  45° 
and  22£'  ,  or  67£°,  which  is  near  enough  for  all  practical 
purposes.     The  line  three  and  three-eighths  inches  long 

i-  tli<ii  laid  off  at  this  angle  by  means  of  the  folded  bit  of 
paper  from  a  spol  half  an  inch  behind  the  mid-point  be- 
tween the  glabella  and  the  external  occipital  protuberances. 


OPERATIONS   UPON  CRANIUM— TREPHINING.     203 

The  paricto-oeeipitcd  fissure. — The  horizontal  limb  of  the 
fissure  of  Sylvius  is  prolonged  to  meet  the  longitudinal 
fissure.  A  trephine  opening  over  the  inner  inch  of  this 
line  will  reveal  a  whole  or  part  of  the  parietooccipital 
fissure.      It  varies  slightly  up  or  down  in  its  location. 

The  frontal  lobe  lies  between  the  lines  indicating  the 
fissures  of  Rolando  and  Sylvius  and  the  longitudinal 
fissure  and  a  line  drawn  from  the  glabella  close  to  and 
parallel  to  the  supra-orbital  arch  to  meet  the  prolongation 
of  the  Sylvian  fissure. 

The  first  frontal  fissure  is  indicated  by  a  line  drawn  from 


Fig.  73. 


Showing  the  position  of  the  cortical  centers  with  reference  to  the  Sylvian  and 
Rolandic  fissures  marked  on  the  surface  of  the  skull.     (Starr.) 

the  supra-orbital  notch  parallel  to  the  longitudinal  fissure 
and  ending  three-quarters  of  an  inch  in  front  of  the  fissure 
of  Rolando. 

The  second  frontal  fissure  is  indicated  by  the  frontal  part 
of  the  temporal  ridge. 

The  ascending  frontal  convolution  occupies  a  space  three- 
quarters  of  an  inch  broad  in  front  of  the  fissure  of  Rolando. 

The  parietcd  lobe  lies  between  the  fissure  of  Rolando, 
the  horizontal  limb  of  the  fissure  of  Sylvius,  the  longi- 
tudinal and  parieto-occipital  fissures. 


204  l-XCISION  OF  JOINTS  AND  BONES. 

The  intra-parietal fissure  begins  on  the  horizontal  limb 
of  the  Sylvian  fissure — more  correctly  a  little  above  it — 
one  inch  behind  its  junction  with  the  fissure  of  Rolando, 
and  passes  upward  three-quarters  of  an  inch  behind  the 
latter  for  the  first  third  of  its  length.  Then  it  arches 
backward  and  downward  and  passes  half  an  inch  to  the 
outer  side  of  the  outer  extremity  of  the  line  indicating  the 
parieto-occipital  fissure. 

The  ascending  parietal  convolution  lies  between  the  fis- 
sure of  Rolando  and  this  first  third  of  the  intra-parietal 
fissure. 

The  inferior  parietal  lobule  lies  between  the  horizontal 
limb  of  the  Sylvian  fissure  and  the  intra-parietal  fissure. 

The  supra-marginal  convolution  occupies  the  anterior 
portion  of  this  space  in  the  most  prominent  part  of  the 
parietal  eminence. 

The  angular  gyrus  occupies  the  posterior  portion. 

The  temporo-sphenoidal  lobe  lies  between  the  Sylvian 
fissure  and  the  base  line,  and  is  limited  behind  by  a  line 
joining  the  termination  of  the  horizontal  limb  of  the  Syl- 
vian fissure,  with  the  center  of  the  line  from  the  external 
occipital  protuberance  to  the  posterior  border  of  the  root 
of  the  mastoid  process. 

Tin:  first  temporo-sphenoidal  fissure  is  indicated  by  a  line 
parallel  to  and  one  inch  below  the  Sylvian  fissure. 

The  second  temporo-sphenoidal  fissure  by  a  line  three- 
quarters  of  an  inch  below  tin-. 

Ko(  iher's  Method. — Koeher  uses  a  specially  con- 
structed instrument  of  pliable  steel  bands  to  mark  out 
the  position  on  the  shaved  seal])  of  the  different  parts  of 
the  brain  which  lie  beneath.  By  reference  to  the  figure 
the  nature  of  this  instrument  can  be  readily  understood. 
An  ordinary  metal  tape  measure  can  be  made  to  answer 
the  purpose.  The  band  A  D  C  E  B  extends  from  the 
glabella  along  the  median  line  to  the  lowest  point  of  the 
external  occipital  protuberance. 

The  horizontal  band  A  .1  !J  Y  B  is  placed  at  right 
angles  to  this  around  the  side  of  the  head  between  the 
same  two  point-.      For  convenience  the  lines  thus  marked 


OPERATIONS   UPON  CRANIUM— TREPHINING.     205 

out  arc  called  the  sagittal  and  horizontal  meridians  of  the 
head. 

From  the  center,  C,  of  the  sagittal  meridian  two  hands 
each  at  the  same  angle  of  60°  to  the  sagittal  meridian 
pass  downward  to  meet  the  horizontal  meridian  at  the 
points  J  and  V. 

The  sagittal  meridian  is  now  divided  into  thirds,  the 
last  of  which  begins  at  E ;  and  next  into  fourths,  the  last 
of  which  begins  at  F.     At  a  point  midway  between  E 

Fig.  74. 


Kocher's  cranial  topography.     (All  the  points  on  the  sagittal  nieridan,  D,  C,  E, 
X,  lie  further  back  than  indicated  in  this  figure.) 


and  F  the  band  X  Y  Z  ii  passes  at  right  angles  to  the 
sagittal  meridian  to  join  the  horizonal  at  IJ,  which  is 
usually  about  half  an  inch  behind  J.  This  oblique  band 
X  il  is  divided  into  thirds  at  Y  and  Z.  C  J  and  C  V 
are  also  divided  into  thirds  at  G,  H,  S,  and  T.  The 
horizontal  meridian  marks  the  lower  border  of  the 
cerebrum.  The  point  J  lies  about  at  the  pterion  or 
junction  of  the  frontal  parietal  and  sphenoidal  bones,  and 
marks  the  anterior  end  of  the  Sylvian  fissure  at  the  spot 


206  EXCISION  OF  JOINTS  AND  BONES. 

where  the  ascending-  joins  the  horizontal  limb.  It  also 
indicates  the  point  of  contact  of  the  frontal  and  temporal 
lobes.  V  lies  over  the  boundary  between  the  temporal 
and  occipital  lobes,  and  is  one  centimeter  below  the  edge 
separating  the  outer  and  under  surfaces  of  the  brain. 

C  indicates  the  uppermost  point  of  the  anterior  central 
convolution  and  is  in  front  of  the  fissure  of  Rolando.  At 
G  the  anterior  central  convolution  meets  the  first  and 
second  frontal  convolutions,  and  at  H  the  second  and 
third.  S  lies  over  the  intra-parietal  fissure  just  above 
the  supra-marginal  gyrus.  T  indicates  the  posterior 
extremity  of  the  first  temporo-sphenoidal  fissure  and  is 
below  the  angular  gyrus.  X  is  over  the  apex  of  the 
lambdoidal  suture  and  at  the  point  of  meeting  of  the 
parieto-occipital  and  great  longitudinal  fissures.  $2  indi- 
cates the  anterior  extremity  of  the  first  temporo-sphe- 
noidal fissure.  The  posterior  end  of  the  first  third  of  the 
sagittal  meridian,  D,  is  at  the  bregma. 

A  trephine  opening  close  to  one  side  of  C  reaches  the 
center  for  the  lower  extremity — the  thigh  and  leg  are 
near  the  middle  line,  the  foot  and  toes  slightly  posterior. 

Between  H  and  G  is  the  center  for  the  upper  extrem- 
ity, in  the  upper  part  and  in  front  of  the  fissure  of  Ro- 
lando the  shoulder  and  elbow  and  in  the  ascending  pari- 
etal convolution  a  little  lower  down  the  center  for  the 
wrist,  fingers,  and  thumb. 

A  little  above  H  the  trephine  exposes  the  center  for 
the  upper  face  muscles,  just  below  H  the  lower  face  mus- 
cles. A  finger-breadth  directly  above  ii  lies  the  center 
governing  the  movements  of  the  larynx  and  pharynx. 

In  front  of  the  middle  of  the  line  H  J  is  the  center, 
injury  to  which  produces  motor  aphasia. 

The  auditory  center  Lies  under  the  posterior  half  of  the 
line  Z  H. 

The  center  for  visual  aphasia  is  below  the  point  T,  and 
jusi  above  the  line  B  Y  is  the  center  for  psychical  vision 
or  psychical  blindness. 

C.  Winkler1  has  elaborated  another  system  of  cerebral 
1  Nederlandsch.  Tijdscbrifi  voor  Geneeekunde,  1892,  p.  158, 


POSITION   OF  THE  LATERAL   SIMS.  207 

topography,  and  Langdon1  still  another.  D'AntonaV 
method  is  simple  and  easily  applied,  but  as  Reid's  original 
scheme  and  its  modifications  are  most  generally  known  and 
used,  it  has  not  seemed  worth  while  to  do  more  than  call 
attention  to  these  few  of  the  numerous  others  which  have 
recently  been  devised. 

THE   POSITION   OF    THE   LATERAL    SINUS. 

According  to  Birmingham3  the  limit  of  the  up-and-down 
variation  of  the  position  of  the  lateral  sinus  is  determined 
thus  :  At  a  point  one  and  a-half  inches  behind  the  center 
of  the  external  auditory  meatus  it  begins  to  arch  down- 
ward. Measure  this  distance  along  the  base  line.  Then, 
at  a  point  one  and  a-quarter  inches  above  the  base  line  at 
this  spot,  draw  a  line  slightly  convex  upward  to  a  point 
half  an  inch  above  the  external  occipital  protuberance. 
Take  another  point  half  an  inch  bdwn  the  external  occipital 
protuberance  and  connect  it  with  the  point  on  the  base  line 
one  and  a-half  inches  behind  the  center  of  the  meatus. 
Outside  of  these  limits  there  is  no  danger  of  opening  the 
lateral  sinus. 

In  its  average  location  it  extends  from  the  external  oc- 
cipital protuberance,  gradually  rising  to  a  point  three- 
quarters  of  an  inch  above  Reid's  base  line.  The  highest 
point  is  reached  one  and  a-half  inches  behind  the  center  of 
the  external  auditory  meatus.  From  here  with  a  gradual 
or  sharp  turn  it  runs  downward  and  forward  on  the  inner 
surface  of  the  mastoid  portion  of  the  temporal  bone  im- 
mediately in  front  of  a  ridge,  which  on  the  outer  surface 
of  the  skull  sometimes  prolongs  the  posterior  margin  of 
the  mastoid  process  upward  and  backward  and  in  front  of 
the  posterior  margin  of  the  process  itself.  Here  it  lies 
about  half  an  inch  behind  the  meatus.  At  the  level  of 
one-quarter  or  one-sixth  inch  below  the  floor  of  the  meatus 
it  turns  into  the  base  of  the  skull. 

To  Open  the  Lateral  Sinus. — Incision  about  two  inches 

1  Cincin.  Med.  Journ.,  Aug.  10,  1894. 

2  Annals  Surg.,  Dec,  1892. 

3  Dub.  Journ.  Med.  Science,  1891,  p.  116. 


208 


EXCISION  OF  JOINTS  AND   BONES. 


in  length,  starting'  near  the  lower  end  of  the  mastoid  proc- 
ess, and  passing  upward  along  the  ridge  on  its  posterior 
margin.  The  periosteum  is  divided  and  elevated.  The 
pin  of  a  three-quarter-inch  trephine  is  placed  at  a  point 
one  and  one-quarter  inches  behind  the  center  of  the  ex- 

Fig.  75. 


A.  External  occipital  protuberance  and  lateral  sinus.  B,  C.  Limit  of  up-and- 
down  variation  in  position  of  the  lateral  sinus.  I).  Incision  for  exposure  of  the 
Gasserian  ganglion. 

ternal  auditory  meatus  on  a  level  with  its  upper  border. 
According  to  Birmingham  this  will  always  open  up  the 
sinus.  The  opening  in  the  hone  may  be  enlarged  as  cir- 
cumstance.- require. 

TREPHINING  FOR  CEREBRAL  ABSCESS  DUE  TO  SUP- 
PURATIVE DISEASE  OF  THE  MIDDLE  EAR. 

The  |»ns  in  these  eases  is  most  frequently  found  in  the 
temporo-sphenoidal  lobe — next  in  order  of  frequency  in 


TREPHINING    FOR   CEREBRAL  AliSCESS. 


209 


the  cerebellum.  According  to  Barker1  the  abscess  gen- 
erally occupies  a  space  between  two  lines  drawn  perpen- 
dicular to  Reid's  base  line.  The  first  passes  through  the 
center  of  the  meatus,  the  second  one  and  one-quarter 
inches  behind  this  (Fig.  7(i,  2). 


Fig 


1.  Trephine  opening  to  enter  the  mastoid  antrum.  2.  Trephine  opening  for 
abscess  following  otitis  media.  3.  Trephine  opening  to  expose  the  cerebellum.  4-5. 
Trephine  opening  for  middle  meningeal  hemorrhage.  A.  Lateral  sinus.  B-C. 
Limit  of  its  up-and-down  variation. 

A  semilunar  incision,  convexity  downward,  is  made  just 
above  and  behind  the  pinna.  The  periosteum  is  divided 
and  elevated  sufficiently  for  the  use  of  a  three-quarter-inch 
trephine.  The  pin  of  this  is  placed  one  and  one-quarter 
inches  above  the  base  line  in  the  center  of  the  space  en- 
closed by  the  perpendiculars.      Birmingham 2  shows  that 


'British  Medical  Journal,  1887,  Vol.  I.,  p.  407. 
2  Dublin  Jour.  Med.  Science,  1891,  p.  119. 


14 


210  EXCISION  OF  JOINTS  AND  BONES. 

in  a  certain  proportion  of  cases  a  trephine  thus  applied 
will  conic  down  on  the  bend  of  the  lateral  sinus,  and  pro- 
poses as  a  safer  location  to  place  the  point  of  the  trephine 
at  least  one  and  three-quarter  inches  above  the  base  line, 
or,  better  still,  two  inches. 

Keen  places  the  pin  of  the  trephine  an  inch  and  a- 
quarter  behind  and  the  same  distance  above  the  external 
auditory  meatus. 

After  the  removal  of  the  button  of  bone  the  dura  is  in- 
cised with  the  knife,  and  the  opening  enlarged  in  the 
shape  of  a  crucial  incision  with  blunt-pointed  scissors. 
The  abscess  is  located  with  an  aspirating  needle,  and  an 
opening  large  enough  for  a  drainage  tube  is  made  with 
some  blunt  instrument. 

The  flaps  are  then  adjusted  and  partially  sutured  in  po- 
sition, leaving  sufficient  room  for  the  escape  of  pus. 

TREPHINING  OF  THE  CEREBELLUM. 

A  transverse  incision  is  made  along  the  superior  curved 
line  of  the  occiput.  Everything  is  divided  down  to  the 
bone.  The  sterno-mastoid,  trapezius,  and  underlying 
muscles  are  raised  with  the  periosteum.  These  soft  parts 
will  contain  the  divided  occipitalis  minor  and  major 
nerves  and  the  occipital  artery.  The  skull  is  opened  below 
the  superior  curved  line  and  behind  the  masto-occipital 
suture  by  placing  the  pin  in  a  three-quarter-inch  trephine 
one  inch  below  Reid's  base  line  at  a  point  two  inches  be- 
hind the  center  of  the  external  auditory  meatus  measured 
along  the  base  line  (Fig.  7<i,  '■>). 

Barker  advises  one  and  one-half  inches  behind  the  cen- 
ter of  the  meatus  and  one  inch  below  the  base  line,  but 
Birmingham  says  a  three-quarter-inch  trephine  would 
wound  the  occipital  artery  in  many  cases  in  this  situation. 

PUNCTURE  OF  THE  LATERAL  VENTRICLES 
(KOCHERj. 

An  inverted  U-shaped  incision  is  made  to  expose  the 
skul]  at  T  i  Fig.  7  1 ).     The  enclosed  flap  should  be  about 


TREPHLNLNQ   EOR  MENINGEAL  HEMORRHAGE.  211 

one  and  one-half  inches  long  by  an  inch  wide.  After  turn- 
ing down  the  >kin  and  securing  the  vessels  the  periosteum 

is  incised  and  elevated,  and  the  point  of  the  trephine  entered 

just  below  and  in  front  of  T.     The  skull  is  thin  in  this 

g    :i.     This  exposes  the  posterior  end  of  the  first  tem- 

poro-sphenoidal  fissure.     The  posterior  horn  of  the  lateral 

ventricle  lies  about  1  cm.  distant  from  the  bottom  of  the 
sulcus  directly  inward. 

Another  method  of  locating  the  opening  to  be  made  in 
the  skull  (Keen)  i-  to  measure  one  and  one-quarter  inches 
back  of  the  external  auditory  meatus  along-  Reid's  base 
line  and  then  one  and  one-quarter  inches  vertically  upward. 
At  this  point  apply  the  pin  of  a  half-inch  trephine.  After 
incising  the  dura  push  a  grooved  director  or  trocar  in  a 
straight  line  toward  a  spot  about  two  and  one-half  or  three 
inches  above  the  opposite  meatus.  The  ventricle  will  nor- 
mally be  reached  at  a  depth  of  about  two  inches — if  dis- 
tended it  lies  somewhat  nearer  the  surface — and  can  be 
recognized  by  the  diminution  of  resistance  offered  to  the 
instrument  and  the  escape  of  fluid  along  the  groove  of  the 
director.  Drainage  is  provided  for  by  inserting  a  small 
rubber  tube  or  a  folded  strip  of  rubber  tissue. 

TREPHINING   FOR   MIDDLE   MENINGEAL 
HEMORRHAGE. 

An  inverted  [J-shaped  incision  is  made  from  the  upper 
part  of  the  posterior  border  of  the  frontal  process  of  the 

malar  bone  upward  nearly  to  the  temporal  ridge,  and  thence 
backward  and  downward  in  a  gentle  curve,  to  terminate 
at  the  superior  border  of  the  posterior  extremity  of  the 
zygoma.  This  flap,  including  a  part  of  the  temporal  mus- 
cle, is  turned  down  and  the  bone  sufficiently  bared  of  peri- 
osteum to  admit  the  use  of  the  trephine  at  the  spot  pres- 
ently to  be  indicated. 

Kocher  makes  an  incision  from  the  external  angular 
process  ot'  the  frontal  bone  to  the  eminentia  articularis, 
thence  upward  and  backward  for  about  an  inch  in  front 
of  the  ear. 

After  the  soft  parts  have  been  raised  the  skull  is  opened 


212  EXCISION  OF  JOINTS  AND  BONES. 

over  the  anterior  division  of  the  artery  by  placing  the  pin 
of  a  three-quarter-inch  trephine  a  thumb's  breadth  behind 
the  external  angular  process  of  the  frontal  bone  and  two 
finger-breadths  above  the  zygoma.  Both  divisions  can 
be  exposed  simultaneously  by  applying  the  trephine  im- 
mediately above  the  middle  of  the  zygoma  (Kocher). 

Kronlein  determines  the  location  of  the  branches  by 
drawing  a  line  through  the  upper  border  of  the  orbit 
backward  parallel  to  Reid's  base  line.  The  anterior  divi- 
sion of  the  artery  lies  on  the  upper  line  3  to  4  cm.  be- 
hind the  external  angular  process  of  the  frontal  bone,  and 
the  posterior  at  the  intersection  of  the  upper  line  with  an- 
other drawn  perpendicular  to  the  base  line  from  a  point 
3  to  4  cm.  behind  the  external  auditory  meatus — roughly, 
from  about  the  posterior  border  of  the  mastoid  process. 

The  following  may  be  taken  as  accurate  enough  for  all 
practical  purposes  :  To  expose  the  anterior  division  of  the 
artery  apply  the  pin  of  a  three-quarter-inch  trephine  one 
inch  above  the  middle  of  the  zygoma  and  then  enlarge 
the  opening  downward  with  the  rongeur  if  it  is  found 
necessary  to  secure  the  trunk  of  the  vessel.  If  for  the 
latter  purpose  the  method  by  osteoplastic  resection  of  the 
skull  is  employed,  the  bone  should  be  chiseled  through  in 
the  lines  of  the  lower  extremities  of  the  inverted  U  inci- 
sion, down  to  the  level  of  the  zygoma  or  nearly  to  the 
pterygoid  ridge  on  the  greater  wing  of  the  sphenoid. 

To  expose  the  posterior  division  of  the  artery  apply  the 
trephine  just  below  the  most  prominent  portion  of  the 
parietal  eminence. 

The  common  indication,  however,  is  rather  to  remove  a 
clot  than  to  arrest  hemorrhage  by  securing  the  trunk  of 
the  artery,  and  the  guide  to  the  site  of  this  clot  is  usually 
to  be  found  in  the  relations  of  the  motor  centers  to  the  ob- 
served paralysis  or  to  a  line  of  fracture.  Ordinarily  a 
trephine  opening  al  the  lower  end  of  the  motor  area  will 
expose  the  clot  directly  or  permit  it  to  be  reached  by 
gently  separating  the  dura  from  the  bone  about  the  opening. 

I  have  -ecu  no  case  in  which  it  became  necessary  to 
secure  the  artery  because  of  hemorrhage  persisting  after 
evacuation  of  the  clot. 


OPENING   OF  THE  FRONTAL  SINUS.  213 

RESECTION  OF  THE  SECOND  AND  THIRD  DIVISIONS 
OF  THE  FIFTH  NERVE  WITHIN  THE  SKULL.1 

The  omega-shaped  incision  is  used  with  its  base  on  the 
zygoma  and  the  top  of  the  curved  part  at  the  temporal 
ridge.     It  starts  at  the  external  angular  process  of  the 

frontal  bone,  and  passes  horizontally  along  the  upper 
border  of  the  zygoma  for  about  half  an  inch.  Thence  in 
the  curved  portion  upward  to  the  temporal  ridge  and 
down  to  the  zygoma  and  again  horizontally  about  half  an 
inch  to  the  tragus  of  the  ear.  The  periosteum  is  divided 
and  the  bone  chiseled  through  and  turned  down  with  its 
attached  soft  parts,  as  already  described. 

The  middle  meningeal  artery  is  secured  by  passing  a 
sharply  curved  needle  and  ligature  beneath  it,  and  the 
dura  is  carefully  separated  from  the  bone  below  so  as  to 
expose  the  middle  fossa  of  the  skull.  Any  hemorrhage  is 
checked  by  pressure. 

With  broad  retractors  the  dura  and  brain  are  lifted, 
taking  great  care  to  avoid  injury  to  the  other  cranial 
nerves  in  the  immediate  vicinity.  The  first,  second,  and 
third  divisions  of  the  fifth  nerve,  as  well  as  the  carotid 
artery  and  cavernous  sinus  are  well  exposed.  The  dura  is 
stripped  back  from  the  second  and  third  divisions  to  be- 
yond the  Gasserian  ganglion,  and  the  parts  lying  between 
it  and  the  foramen  ovale  and  rotund um  are  excised.  The 
flap  is  then  replaced  and  united  with  interrupted  silk 
sutures. 

OPENING   OF   THE   FRONTAL    SINUS. 

The  eyebrow  is  shaved.  The  incision  starts  at  the  cen- 
ter of  the  supra-orbital  ridge  and  follows  the  curve  of  the 
upper  border  of  the  eyebrow  to  the  median  line  above  the 
root  of  the  nose.  Everything  is  divided  down  to  the  bone 
— the  periosteum  is  raised  on  each  side  and  the  trephine 
or  chisel  entered  at  the  inner  end  of  the  superciliary  ridge. 

Antrum  of  Highmore. — A  very  small  trephine  should 
be  used,  and,  in  order  to  avoid  a  scar,  it  should  be  ap- 
plied through  the  mouth  after  dividing  the  gingivo- 
1  Hartley:    N.  Y.  Med.  Journ.,  1893,  Vol.  55,  p.  317. 


214  EXCISION  OF  JOINTS  AND  BONES. 

labial  fold,  and  dissecting-  up  the  soft  parts  as  far  as  to 
the  infra-orbital  foramen,  just  below  and  to  the  outer  side 
of  which  the  opening  into  the  antrum  should  be  made. 

The  antrum  may  also  be  opened  by  drawing  the  first  or 
second  molar  tooth,  and  enlarging  its  socket  with  a  drill. 

No  additional  directions  are  needed  for  trephining  the 
flat  bones  or  the  epiphyses  of  the  long  ones. 


PART  V. 

NEUROTOMY,  TENOTOMY,  OSTEOTOMY  AND 
MISCELLANEOUS   OPERATIONS. 


DIVISION   AND  RESECTION  OF   NERVES." 

Division  of  a  nerve  of  sensation,  or  even  of  a  mixed 
nerve  in  extreme  cases,  may  be  required  for  the  relief  of 
neuralgic  pain.  It  is  seldom  that  a  simple  division  is 
more  than  temporarily  sufficient.  At  least  half  an  inch 
of  the  trunk  of  the  nerve  should  be  excised,  and,  as  addi- 
tional security  against  reunion,  the  end  of  the  distal  seg- 
ment may  be  bent  back  upon  itself.  Professor  Weir 
Mitchell 2  has  seen  severe  constant  pain  follow  the  bend- 
ing back  of  the  end  of  the  proximal  segment. 

SUPRA-ORBITAL   NERVE. 

The  frontal  nerve,  main  branch  of  the  first  division  of 
the  trigeminus,  divides  just  behind  the  upper  margin  of 
the  orbit  into  the  supra-orbital  and  supra-trochlear  nerves  ; 
both  branches  are  distributed  to  the  forehead,  the  former 
emerging  from  the  orbit  through  the  supra-orbital  notch 
or  foramen,  the  latter  a  little  nearer  the  nose.  The 
former  is  much  the  larger  and  more  important  of  the 
two,  the  latter  supplying  only  a  narrow  strip  of  integu- 
ment near  the  median  line.  The  supra-orbital  notch  or 
foramen  is  found  at  the  junction  of  the  inner  and  middle 
thirds  of  the  supra-orbital  arch,  or  a  little  to  the  inner 
side  of  the  junction.     When  it  is  a  notch  it  can  be  readily 

1 A  description  of  all  known  operations  on  cranial  nerves,  with  the 
bibliography,  can  be  found  in  Chir.  Operat.  du  Svst.  Nerveux,  bv 
Chipault.     Paris  :  Rueff  &  Co.,  1894. 

2  Oral  communication. 

215 


216 


VISC ELL ANEO  US  OPERA  TIONS. 


fell  through  the  skin,  and  is  then  an  important  guide  in 
the  operation. 

The  nerve  may  be  divided  subcutaneously  after  its 
emergence  from  the  notch,  or  it  may  be  exposed  by  a  trans- 
verse incision  above  or  below  the  eyebrow. 

Subcutaneous  Division. — A  tenotomy  knife  is  entered 
between  the  eyebrows  midway  between  the  nerve  and  the 
median  line,  and  passed  horizontally  beneath  the  skin  until 
its  point  has  passed  beyond  the  nerve.  Its  edge  is  then 
turned  backward  and  pressed  against  the  bone,  and  the 
nerve,  lying  between  it  and  the  bone,  divided  by  with- 
drawing the  knife.     Or  the  knife  may  be  entered  at  the 


A,  /:.  Resection  of  supra-orbital  nerve.  C.  Resection  of  superior  maxillary  nervo- 
sa me  point,  but  passed  close  to  the  bone  instead  of  just 
under  the  skin,  its  edge  turned  downward  toward  the 
margin  of  the  orbit,  and  the  nerve  divided  by  sweeping 
the  knife  downward  across  the  mouth  of  the  supra-orbital 
foramen. 

Excision  of  a  Portion  of  the  Nerve.  A.  ABOVE  THE 
EYEBROW.  (T'ig.  77,  A.) — An  incision  one  to  one  and  a- 
half  inches  long  is  made  just  above  and  parallel  to  the  eye- 
brow, it-  center  corresponding  to  the  position  of  the  nerve. 
This  incision  is  carried  down  to  the  hone,  the  distal  end  of 
the  nerve  recognized,  seized  with  forceps,  dissected  out, 
and  cut  off. 


SUPERIOR  MAXILLARY  NERVE.  217 

B.  Below  the  Eyebrow.  (Fig.  77,  B.) — The  eye- 
brow being  drawn  up  and  the  eyelid  down,  the  surgeon 
makes  an  incision  one  to  one  and  a-half  inches  in  length 
along  the  edge  of  the  supra-orbital  arch,  dividing  succes- 
sively the  skin,  orbicular  muscle,  ami  tarsal  ligament.  He 
then  seeks  the  nerve  in  the  notch,  traces  it  back  as  far  as 
necessary,  while  depressing  the  eye  and  levator  palpebra? 
with  a  retractor,  and  cuts  out  a  portion  with  curved  scis- 
sors. 

Supra-trochlear  Nerve. — K5nig  resected  this  nerve 
by  making  a  curved  incision  under  the  eyebrow  at  the 
upper  inner  edge  of  the  orbit,  and  seeking  the  trochlea  and 
the  superior  oblique  muscle.  On  making  the  latter  tense 
with  a  hook  the  two  fine  nerves  became  visible,  were  seized 
with  forceps,  and  resected. 

SUPERIOR  MAXILLARY   NERVE. 

After  leaving  the  cavity  of  the  cranium  by  the  foramen 
rotundum,  the  superior  maxillary  nerve  crosses  the  spheno- 
maxillary fossa,  traverses  the  infra-orbital  canal,  and  ap- 
pears upon  the  face  at  the  infra-orbital  foramen,  where  it 
at  once  divides  up  into  numerous  branches  distributed  over 
the  cheek,  nose,  lip,  and  lower  eyelid.  Within  the  infra- 
orbital canal  it  gives  off  the  anterior  dental  branch,  and 
posterior  to  this  canal  it  gives  off  the  posterior  dental,  and, 
through  branches  to  the  spheno-palatine  ganglion,  the 
palatine  nerves  distributed  to  the  palate  and  nasal  fossa. 
The  point  at  which  the  nerve  should  be  divided  will  vary 
according  to  the  region  affected ;  but  in  this,  as  in  other 
cases,  simple  division  has  usually  proved  insufficient,  and 
it  has  been  found  necessary  to  excise  all  that  portion  of  the 
trunk  which  lies  in  the  canal.  Sometimes  the  nerve  has 
been  cut  above  the  branches  going  to  the  ganglion,  and  the 
latter  torn  out  forcibly. 

The  roof  of  the  infra-orbital  canal  is  composed  in  its 
posterior  half  of  fibrous  tissue,  in  its  anterior  half  of  thin 
bone,  which  becomes  thicker  as  it  approaches  the  margin 
of  the  orbit.  The  infra-orbital  foramen  lies  directly  above 
the  second  bicuspid  tooth  and  from  one-quarter  to  one-half 


218  MISCELLANEOUS  OPERATIONS. 

an  inch  below  the  margin  of  the  orbit.  The  nerve  is  ac- 
companied on  its  passage  through  the  canal  by  the  infra- 
orbital artery. 

A.  Division  of  the  Nerve  ox  the  Face. — This 
may  be  done  :  (1)  subcutaneously  ;  (2)  through  the  mouth  ; 
(3)   by  an  externa!  incision, 

1.  Subcutaneously. — A  tenotomy  knife  is  entered  about 
an  inch  to  the  outer  side  of  the  foramen,  carried  below  it 
into  the  canine  fossa,  hugging  the  bone,  and  then  swept 
upward  along  the  surface  of  the  bone  so  as  to  divide  the 
nerve  close  to  the  foramen,  the  lip  being  drawn  downward 
and  forward  to  make  the  tissues  tense. 

2.  Through  the  Mouth. — An  incision  is  made  in  the 
gingivo-labial  fold,  and  the  soft  parts  dissected  away  from 
the  bone  until  the  nerve  is  reached  and  divided. 

3.  By  External  Incision. — The  incision  may  be  trans- 
verse, oblique,  or  curved ;  it  is  only  necessary  that  its 
center  should  correspond  to  the  foramen.  The  tissues 
are  divided  successively  until  the  bone  is  reached  and  the 
nerve  found  either  by  following  up  one  of  its  branches  or 
by  seeking  it  at  its  point  of  emergence. 

B.  Resection  of  the  Infra-orbital  Portion. 
(Tillaux1.)  (Fig.  77,  C.) — A  vertical  incision  is  made 
along  the  side  of  the  nose  from  the  lachrymal  tubercle  or 
the  bony  ridge  of  the  nasal  process  of  the  superior  max- 
illa, which  is  continuous  with  the  lower  edge  of  the  orbit, 
down  to  the  ala  of  the  nose.  A  second  horizontal  one  is 
thru  begun  at  the  upper  portion  of  the  first  and  carried 
outward  along  the  lower  margin  of  the  orbit  beyond  its 
center.  These  incisions  should  involve  all  the  soft  parts 
down  to  the  bone.  The  lower  flap  is  dissected  up,  the 
nerve  found,  and  a  silk  ligature  thrown  around  it  close  to 
the  foramen. 

Tin'  upper  flap  is  then  raised,  together  with  the  lower 
eyelid  and  eyeball,  exposing  the  floor  of  the  orbit  as  far 
back  as  possible,  upon  which  the  infra-orbital  canal  can 
lie  recognized  as  a  grayish  line  running  obliquely  back- 
ward and  inward. 

'Tr;iit<'  d'Anat.  Topographique,  p.  310,  and  Bull  de  la  Society  de 
Chirurgie,  1878,  j>.  US. 


SUPERIOR  MAXILLARY   A/.// 17.  2H) 

The  canal  is  opened  with  a  knife  or  chisel,  the  nerve 
isolated  from  the  artery,  raised  from  its  bed  with  a  small 
hook,  and  dissected  out  as  far  back  as  may  be  considered 
accessary.  It  is  then  divided  with  curved  scissors,  and 
the  distal  portion  drawn  out  by  means  of  the  ligature 
applied  to  it  in  the  beginning.  The  length  of  the  portion 
removed  by  Tillaux  was  six  centimeters. 

Dolbeau  l  divided  the  nerve  with  curved  scissors  on  the 
central  side  of  the  branches  going  to  the  spheno-palatine 
ganglion,  and  tore  out  the  ganglion  by  drawing  upon  the 
nerve. 

LuckeJs  Method.2 — An  incision,  beginning  one  centimeter 
above  the  outer  angle  of  the  eye  and  close  behind  the 
margin  of  the  orbit,  is  carried  downward  and  slightly  for- 
ward across  the  malar  bone,  dividing  its  periosteum  ; 
from  its  lower  end  a  second  incision  is  carried  backward 
and  upward,  terminating  over  the  outer  surface  of  the 
zygomatic  process  of  the  temporal,  about  a  quarter  of  an 
inch  behind  its  junction  with  the  malar  bone.  The  latter 
bone  is  next  divided  in  the  line  of  the  first  incision  by 
means  of  a  saw  or  chisel,  after  preliminary  division  of  the 
soft  parts  and  periosteum  on  its  under  and  inner  surface 
with  a  small  knife,  and  the  zygoma  then  cut  through  at 
its  posterior  extremity.  The  attachments  of  the  masseter 
to  the  intermediate  piece  are  then  separated,  and  the  flap 
of  bone  and  soft  parts  raised  with  a  sharp  hook. 

If  necessary,  some  of  the  anterior  fibers  of  the  temporal 
muscle  should  now  be  divided  in  order  to  expose  the 
sphenomaxillary  fossa  thoroughly,  the  fat  occupying  the 
fossa  pressed  backward  with  a  retractor,  and  the  spheno- 
maxillary fissure  recognized  with  a  probe.  The  nerve 
and  artery  can  be  distinguished  by  the  difference  in  their 
course,  the  former  running  downward,  outward,  and  for- 
ward, the  latter  upward,  inward,  and  forward.  The  nerve 
is  seized  with  forceps  and  divided  with  a  tenotome  well 
forward  in  the  fissure,  and  then  again  with  scissors  as 
near  as  possible  to  the   foramen  rotundum.     The  flap  is 

JOral  communication. 

2  Deutsche  Zeitschrift  fur  Ohirurgie.  Vol.  4,  p.  322. 


220  MISCELLANEOUS  OPERATIONS. 

then  put  back,  and  the  wound  drained  at  its  lower  angle. 

An  objection  to  this  method  is  that,  in  consequence  of 
its  interference  with  the  masseter  and  temporal  muscles, 
the  mouth  subsequently  cannot  be  freely  opened.  Lossen 
and  Braun  '  avoid  this  difficulty  by  leaving  the  attach- 
ments of  the  masseter  untouched  and  turning  the  flap 
downward  instead  of  upward,  after  making  the  second  in- 
cision from  the  upper  end  of  the  first  instead  of  from  its 
lower  end  and  separating  the  temporal  fascia  from  the 
malar  bone.  Czerny 2  has  employed  this  modification 
five  times  with  good  results. 

If  wounded  vessels  cannot  be  seized  and  tied,  the  hem- 
orrhage must  be  arrested  by  plugging  with  antiseptic 
gauze. 

INFERIOR   DENTAL   NERVE. 

This  nerve  may  be  divided  (A)  after  its  exit  from  the 
dental  canal,  (B)  in  the  canal,  (C)  before  its  entrance  into 
the  canal.  The  nerve  enters  the  canal  by  the  inferior 
dental  foramen  on  the  inner  side  of  the  ascending  ramus 
of  the  lower  jaw  at  the  level  of  the  crowns  of  the  lower 
teeth  ;  the  canal  runs  obliquely  downward  and  forward 
just  below  the  alveoli  and  the  nerve  emerges  through  the 
mental  foramen  which  lies  midway  between  the  alveolar 
process  and  the  lower  margin  of  the  jaw  below  the  second 
bicuspid  tooth. 

A.  At  the  Mental  Foramen. — An  incision  is  made 
in  the  gmgivo-labial  fold  above  the  foramen  and  the  soft 
parts  dissected  off  until  the  nerve  is  reached,  usually 
about  one-third  of  an  inch  below  the  bottom  of  the  fold. 

B.  WlTHIN  the  Canal. — An  incision  is  made  through 
the  skin  down  to  the  bone  along  the  course  of  the  nerve 
in  front  of  the  masseter,  the  periosteum  raised,  and  the 
canal  opened  with  a  chisel  or  small  trephine.  After  re- 
moval of  the  outer  table  of  the  bone  the  nerve  is  easily 
found  in  the  canal  and  divided. 

<  )r  flu:  canal  may  be  opened  at  two  points  and  the  inter- 

mediate  portion  of  the  nerve  excised. 

1 '  Viitni]l>l;itt  I'iir  <  liirur^ic,  1S78,  pp.  (io  and  148. 
[bid.,  1882,  p.  249. 


INFERIOR  DENTAL  NERVE.  221 

Another  method  is  to  make  a  curved  incision  behind 
and  below  the  angle  of  the  jaw,  and  elevate  the  periosteum 
and  masseter  on  its  outer  surface  as  far  as  the  alveolar 
margin.  Then  chisel  into  the  middle  of  the  exposed 
bone.     The  oral  cavity  should  not  be  opened. 

C.  Before  its  Entry  into  the  Canal.  1.  From 
vithin  the  mouth. — The  mouth  being  held  widely  open  and 
the  commissure  of  the  lips  drawn  backward  and  outward, 
an  incision  extending  from  the  last  upper  to  the  last  lower 
molar  tooth  is  made  one-third  of  an  inch  on  the  inner  side 
of  the  sharp  anterior  border  of  the  coronoid  process,  and 
carried  through  the  mucous  membrane  to  the  tendon  of 
the  temporal  muscle. 

The  surgeon  passes  his  finger  into  the  incision  and  along 
the  inner  surface  of  the  bone,  between  it  and  the  internal 
pterygoid  muscle,  until  he  touches  the  bony  point  which 
marks  the  orifice  of  the  canal.  Passing  a  blunt  hook 
along  the  finger,  he  raises  the  nerve  upon  it,  isolating  it 
if  possible  from  the  accompanying  artery,  and  divides  it 
with  blunt-pointed  scissors  or  knife.  Or,  without  intro- 
ducing the  finger,  the  hook  may  be  passed  back  beyond  the 
nerve,  its  point  constantly  in  contact  with  the  bone,  then 
rotated  inward  so  as  to  carry  its  point  across  and  behind 
the  nerve,  and  then  withdrawn. 

2.  Through  the  check. — A  curved  incision  is  made  around 
the  angle  of  the  jawr  or  around  the  lower  anterior  insertion 
of  the  masseter  and  carried  through  to  the  bone  along  its 
lower  portion  ;  then  with  the  elevator  and  knife  the  muscle 
is  detached  from  below  upward,  and  the  flap  raised  with  a 
hook  until  the  level  of  the  inferior  dental  foramen  is 
reached.  The  bone  is  then  cut  away  with  a  chisel  or  small 
trephine  and  the  nerve  exposed  and  excised. 

With  the  same  curved  incision  around  the  angle  of  the 
jaw  the  inner  surface  of  the  latter  may  be  freed  from  the 
periosteum  and  internal  pterygoid  muscle  upward  till  the 
lingula  is  felt;  then,  with  or  without  dividing  this  proc- 
ess the  nerve  can  be  isolated  and  divided.  Or  a  vertical 
incision  may  be  made  through  the  skin  and  fascia,  the 
fibers  of  the  masseter  separated,  and  the  bone  thus  exposed. 


222  MISCELLANEOUS  OPERATIONS. 

At  the  Foramen  Ovale. — Bnum's  modification  of 
Liicke's  method  for  exposing  the  superior  maxillary  nerve 
can  be  employed  with  slight  changes  for  this  purpose. 
The  temporal  muscle  must  be  retracted  or  partially  divided 
near  its  insertion,  or  the  eoronoid  process  cut  through  at 
its  base. 

Kronlein  '  suggests  the  following  method  :  An  incision 
is  made  from  half  an  inch  behind  the  angle  of  the  mouth 
to  terminate  a  similar  distance  in  front  of  the  lobule  of 
the  ear.  Only  the  skin  and  subcutaneous  fat  are  divided, 
the  buccinator  and  oral  mucous  membrane  being  spared. 
The  masseter  is  cut  back  to  the  anterior  border  of  the 
parotid  gland,  thus  sparing  the  latter  and  Steno's  duct, 
which  lies  well  above  the  line  of  incision.  The  eoronoid 
process  is  bared  at  its  base  with  a  periosteal  elevator, 
divided  from  the  semilunar  notch  downward  and  forward, 
and  drawn  upward,  together  with  the  attached  temporal 
muscle.  The  branches  of  the  inferior  maxillary  nerve  are 
then  exposed  by  a  blunt  dissection  on  the  outer  surface  of 
the  internal  pterygoid  muscle.  The  external  pterygoid  is 
drawn  upward  and  the  nerves  traced  back  to  the  base  of 
the  skull.  At  the  close  of  the  operation  the  eoronoid  proc- 
ess and  divided  masseter  muscle  are  sutured. 

He  exposes  the  superior  and  inferior  maxillary  nerves 
simultaneously  at  their  exit  from  the  skull  in  the  follow- 
ing manner2:  A  curved  incision,  concavity  upward,  is 
made,  starting  from  the  most  prominent  portion  of  the 
malar  bone,  passing  down  to  the  level  of  the  lobule  of  the 
ear,  thence  backward  and  upward  in  a  gentle  curve,  to 
terminate  over  the  posterior  extremity  of  the  zygoma. 
The  flap  of  skin  and  subcutaneous  fascia  is  turned  up,  the 
temporal  fascia  divided  along  the  upper  border  of  the 
zygoma,  and  the  latter  sawn  through  at  its  anterior  and 
posterior  extremities,  as  in  Liicke's  operation.  The  eoro- 
noid process  i>  exposed  and  cut  through  at  its  base  down- 
ward and  forward,  and  drawn  upward  with  the  attached 
temporal  muscle.      The  internal  maxillary  artery  is  secured 

1  Archiv.  f.  klin.  Chir.,  Bd.  X  1,1 1 1.,  |>.  L3. 
Dentsch.  Zeitsch.  f.  Chir.,  L884,  Vol.  XX..  \>.  484. 


BUCCAL  NERVE.  223 

and  the  attachment  of  the  external  pterygoid  muscle  sep- 
arated from  the  under  surface  of  sphenoid  bone.  This 
exposes  the  inferior  maxillary  nerve  at  the  foramen  ovale,, 
and  by  working  along  the  sphcno-maxillary  fissure  the 
superior  maxillary  nerve  is  found  and  followed  back  to 
the  foramen  rotundum.  At  the  close  of  the  operation  the 
parts  are  replaced  and  sutured  in  their  proper  position. 

Salgcr l  recommends  a  curved  incision,  convexity  up- 
ward, extending  from  one  extremity  of  the  zygoma  to  the 
other.  Everything  is  divided  down  to  the  skull,  the 
zygoma  sawn  through  at  each  extremity,  and  the  flap  of 
skin,  fascia,  temporal  muscle,  and  zygoma  turned  down. 
The  coronoid  process  is  depressed  by  opening  the  mouth, 
and  the  nerve  found  below  the  external  and  on  the  outer 
surface  of  the  internal  pterygoid  muscle,  and  divided  as 
high  up  as  desired. 

BUCCAL   NERVE. 

The  buccal  nerve,  a  branch  of  the  inferior  maxillary, 
may  be  the  seat  of  painful  and  persistent  neuralgia.  It 
is  best  approached  through  the  mouth  by  the  following 
method  : 

The  surgeon  places  his  finger-nail  upon  the  outer  lip  of 
the  anterior  border  of  the  ascending  ramus  of  the  lower 
jaw  at  its  center,  and  divides  in  front  of  this  border  the 
mucous  membrane  and  the  fibers  of  the  buccinator  verti- 
cally. He  then  seeks  for  the  nerve,  separating  the  tissues 
with  a  director,  and  divides  it. 

Zuckerkandl  exposes  the  nerve  from  the  outside  of  the 
cheek.  A  horizontal  incision  a  finger's  breadth  below  the 
zygoma  is  made  from  the  anterior  border  of  the  masse ter 
muscle  nearly  to  the  canine  eminence.  The  fascia  over- 
lying Steno's  duct  is  divided,  and  the  latter  exposed  and 
drawn  downward  with  its  accompanying  nerves.  The  fat 
on  the  posterior  part  of  the  buccinator  muscle  is  torn 
through,  and  the  nerve  found  to  the  inner  side  of  the  in- 
sertion of  the  temporal  muscle  on  the  front  of  the  coronoid 
process.  It  lies  about  an  inch  back  of  the  anterior  border 
of  the  masseter  muscle. 

■Wien.  med.  Wochenscbr.,  1887,  Vol.  XXXVII.,  p.  461. 


224  MISCELLANEOUS  OPERATIONS. 

LINGUAL    NERVE. 

Division  of  this  nerve  may  be  required  for  the  relief  of 
pain  in  cases  of  carcinoma  of  the  tongue. 

When  the  mouth  is  opened  widely  the  pterygo-maxil- 
lary  ligament  can  be  readily  seen  and  felt  as  a  prominent 
fold  behind  the  last  lower  molar,  and  the  lingual  nerve 
can  be  felt  just  below  the  attachment  of  the  ligament  on 
the  inner  side  of  the  lower  jaw,  close  to  the  bone  below 
the  last  molar  tooth. 

The  tongue  should  be  drawn  aside  by  an  assistant,  the 
mucous  membrane  divided  for  about  an  inch  parallel  to 
the  margin  of  the  alveolar  process,  beginning  at  the  last 
molar  tooth  over  the  position  of  the  nerve,  or,  according 
to  Chauvel,1  one-fifth  of  an  inch  from  the  attachment  of 
the  mucous  membrane  to  the  side  of  the  tongue.  The 
nerve  is  then  readily  found  in  the  submucous  tissue, 
raised  upon  a  hook  and  divided,  or  a  portion  excised. 

Moore's  Method. — Mr.  Moore  has  employed  the  follow- 
ing method  successfully  in  five  cases  :  He  cuts  the  nerve 
about  half  an  inch  from  the  last  molar  tooth,  at  a  point 
where  it  crosses  an  imaginary  line  drawn  from  that  tooth 
to  the  angle  of  the  jaw.  He  enters  the  point  of  the  knife 
nearly  three-quarters  of  an  inch  behind  and  below  the 
tooth,  presses  it  down  to  the  bono  and  cuts  toward  the 
tooth.  This  necessarily  divides  the  nerve.  This  projec- 
tion of  the  alveolar  ridge  might  protect  the  nerve  from 
a  straight  bistoury,  and  therefore  a  curved  one  should 
be  used. 

The  lingual  nerve  may  also  be  reached  from  outside 
the  mouth  by  any  one  of  the  methods  for  resecting  the 
inferior  maxillary,  or  by  an  incision  along  the  lower  border 
of  the  jaw  just  in  front  of  the  massetcr  muscle.  In  the 
latter  case  (Lobker)  the  upper  margin  of  the  wound  is 
drawn  up  and  a  portion  of  the  inferior  maxilla,  where  the 
alveolar  process  adjoins  the  ramus,  is  exsected  and  the 
nerve  exposed  on  the  outer  surface  of  the  internal  ptery- 
goid.    ( )r  the  dissection  caD  be  carried  up  under  the  inner 

1  I'n'cis  d'<  )|i('r:itions  do  Cliinirgie,  p.  435, 


BRACHIAL  PLEXUS.  225 

surface  of  the  jaw  (Luschka).     The  submaxillary  gland  is 

displaced  downward  and  forward,  the  posterior  border  of 
the  mylohyoid  muscle  divided  and  the  nerve  found  under 
the  posterior  end  of  the  sublingual  gland.  Thence  it  can 
be  followed  backward  and  upward  and  divided  as  high  as 
desired. 

FACIAL  NERVE. 

This  nerve  has  occasionally  been  stretched  and  crushed 
for  the  relief  of  clonic  spasms  of  the  corresponding  mus- 
cles. A  semilunar  incision  is  made  around  the  lower 
attachment  of  the  ear  with  a  short  liberating  incision 
downward  from  its  center ;  the  flaps  are  dissected  back, 
and  the  nerve  exposed  by  drawing  the  parotid  forward 
and  outward. 

The  nerve  is  more  easily  exposed  at  the  posterior  border 
of  the  ramus.  For  this  an  incision  is  made  from  just  in 
front  of  the  tragus  of  the  ear  to  the  angle  of  the  jaw. 
After  dividing  the  parotid  fascia  the  cervico-facial  branch 
will  probably  be  exposed  first,  and  can  then  be  followed 
back  to  its  junction  with  the  temporo-facial. 

BRACHIAL   PLEXUS. 

This  plexus  consists  of  the  four  lower  cervical  nerves 
and  the  greater  part  of  the  first  dorsal.  It  crosses  the 
floor  of  the  subclavian  triangle  of  the  neck,  and  lies  be- 
tween the  anterior  and  middle  scaleni  muscles.  Its  shape 
is  triangular,  with  the  base  at  the  spine  and  the  apex  to 
the  outer  side  of  the  subclavian  artery  below  the  clavicle. 

Operation. — The  head  and  neck  are  extended,  and  the 
face  turned  to  the  opposite  side.  An  incision,  starting 
half  an  inch  above  the  clavicle  in  the  interval  between  the 
sterno-cleido-mastoid  and  trapezius,  is  carried  forward,  for 
about  three  inches,  parallel  to  the  anterior  border  of  the 
latter.  The  skin  and  platysma  are  divided  and  the  ex- 
ternal jugular  vein  either  cut  between  two  ligatures  or 
drawn  to  one  side.  The  deep  cervical  fascia  is  divided  in 
the  line  of  the  external  incision,  avoiding  the  supra- 
15 


22 ( '»  .1/ [S(  EL  L .  1 NEO  US  OPERA  TIONS. 

clavicular  branches  of  the  cervical  plexus,  and  the  outer 
border  of  the  anterior  scalenus  muscle  recognized.  The 
plexus  is  felt  with  the  finger  just  outside  the  latter  and 
isolated  by  a  little  careful  dissection.  Any  particular 
cord  can  he  identified  by  tracing  it  to  its  point  of  emer- 
gence from  the  spine  through  the  interval  between  the 
scaleni  muscles. 

Resection  of  the  Posterior  Roots  of  the  Brachial  Plexus. — 
This  operation  has  been  performed  several  times  for 
severe  neuralgia  of  the  peripheral  branches.  An  incision 
about  six  inches  long,  with  its  ceuter  just  above  the  spine 
of  the  seventh  cervical  vertebra,  is  made  parallel  and 
close  to  the  ligamentum  nucha?  and  deepened  alongside  of 
the  spines  till  the  laminae  of  the  fifth,  sixth,  and  seventh 
vertebra?  are  reached.  These  lamina?  are  then  bared  of 
soft  parts  on  the  affected  side  out  to  the  bases  of  the  artic- 
ular processes,  and  removed  with  the  chisel,  rongeur,  or 
bone  forceps,  thus  exposing  the  posterior  roots  of  the 
nerves  previous  to  their  exit  from  the  intervertebral 
foramina. 

CERVICAL   PLEXUS. 

An  incision  about  two  inches  in  length  is  made  parallel 
to  and  over  the  posterior  border  of  the  sterno-mastoid 
muscle.  Its  center  should  correspond  to  the  center  of  the 
muscle.  The  skin,  superficial  fascia,  and  platysma  are 
divided  and  the  superficial  branches  of  the  cervical  plexus 
are  exposed  at  the  middle  of  the  posterior  border  of  the 
sterno-mastoid  muscle  and  can  be  traced  back  toward  the 
spine. 

SPINAL    ACCESSORY    NERVE. 

After  passing  outward  beneath  the  digastric  and  stylo- 
hyoid muscles  and  occipital  artery,  the  nerve  about  half 
an  inch  below  the  apex  of  1 1 x?  mastoid  process  enters  the 
under  surface  of  the  sterno-mastoid  muscle  in  its  upper 
part,  leaves  it  at  about  the  center  of  its  posterior  border, 
and  passes  beneath  the  trapezius  at  about  the  junction  of 
the  middle  and  lower  thirds  of  its  anterior  border.  In 
the  substance  of  the  sterno-mastoid  muscle  it  communi- 


SPINAL  ACCESSORY  NERVE.  227 

ontos  with  the  second  cervical  nerve,  in  the  occipital  tri- 
angle with  the  second  and  third,  and  beneath  the  trapezius 
with  the  third  and  fourth  cervical  nerves. 

Operation. — An  incision  about  three  inches  long  is  made 
downward  from  the  tip  of  the  mastoid  process  along  the 
anterior  border  of  the  sterno-mastoid  muscle,  the  cervical 
fascia  divided  and  the  muscle  strongly  retracted  to  put 
the  nerve  on  the  stretch.  The  nerve  is  then  sought  for 
external  to  the  jugular  vein  about  an  inch  and  a-half  be- 
low the  tip  of  the  mastoid  process  on  the  fascia  covering 
the  rectus  capitis  auticus  major. 

Section  of  the  Posterior  Divisions  of  the  First,  Second 
and  Third  Cervical  Nerves  for  Spasmodic  Wry  Neck. — The 
chief  posterior  cervical  rotators  of  the  head  and  their 
nerve  supply  are  as  follows  :  The  rectus  capitis  posticus 
major  is  supplied  by  the  suboccipital  or  posterior  division 
of  the  first  cervical  nerve.  The  inferior  oblique  is  sup- 
plied by  the  posterior  divisions  of  the  first  and  second 
cervical  nerves  and  the  splenitis  capitis  by  the  posterior 
divisions  of  the  second  and  third  cervical  nerves. 

Operation.  (Modified  from  Keen.)1 — A  transverse  in- 
cision about  three  inches  long  is  made  extending  hori- 
zontally outward  from  the  middle  line  of  the  neck,  or 
slightly  overlapping  it,  an  inch  and  a-half  below  the  ex- 
ternal occipital  protuberance.  It  is  carried  through  the 
trapezius  and  posterior  border  of  the  splenius  capitis 
muscles  until  the  complexus  is  recognized,  the  trapezius 
is  dissected  up  from  the  complexus  and  the  occipitalis 
major  nerve  found  at  the  upper  part  of  the  complexus. 
Divide  the  complexus  transversely  and  follow  the  nerve 
back  to  its  origin  from  the  posterior  division  of  the  sec- 
ond cervical  nerve  and  divide  the  latter  as  near  the  verte- 
bra as  possible. 

Recognize  the  suboccipital  triangle,  which  is  bounded 
by  the  superior  and  inferior  oblique  and  the  rectus  capitis 
posticus  major  muscles.  Within  this  lies  the  suboccipital 
nerve  close  to  the  occiput  and  vertebral  artery  ;  it  must 
be  traced  and  severed  close  to  the  spine.     The  posterior 

1  Annals  Surg.,  Jan.,  1891. 


22S  MISCELLANEOUS  OPERATIONS. 

division  of  the  third  cervical  nerve  is  found  beneath  the 
complexus  about  an  inch  lower  down  than  the  occipitalis 
major,  and  must  be  cut  close  to  the  bifurcation  of  the 
main  trunk. 

Smith '  made  a  longitudinal  incision  about  three  inches 
long;  from  the  occiput  downward  about  an  inch  and  a-half 
to  one  side  of  the  middle  line.  It  passed  through  the 
trapezius  to  the  edge  of  the  splenius,  then  through  the 
complexus,  and  eventually  exposed  the  posterior  divisions 
of  the  cervical  nerves.  The  great  occipital  nerve  was 
recognized,  separated,  and  drawn  aside  ;  a  part  of  the  exter- 
nal branch  of  the  posterior  division  of  the  second  nerve 
was  excised  ;  the  splenius  and  complexus  separated  from 
the  parts  beneath,  and  the  entering  nerve  filaments  divided. 

The  suboccipital  nerve  Mas  not  divided.  The  result  of 
this  operation  seems  to  have  been  perfect. 

Median  Nerve. — In  the  arm  it  is  exposed  by  the  method 
given  for  ligation  of  the  brachial  artery.  At  the  wrist  it 
is  reached  by  an  incision  about  an  inch  and  a-half  long, 
parallel  to  and  just  to  the  ulnar  side  of  the  tendon  of  the 
palmaris  longus. 

Ulnar  Nerve. — Except  in  the  extreme  upper  part  of  its 
course  the  nerve  closely  accompanies  the  triceps  and  is 
completely  separated  from  the  median  nerve  and  brachial 
artery  by  the  fascial  septum  that  passes  down  to  the  bone 
between  the  biceps  and  triceps.  Except  near  the  elbow, 
it  should  be  sought  through  an  incision  parallel  to  and  a 
little  posterior  to  the  brachial  artery,  and  after  exposure 
of  the  triceps. 

At  the  elbow  it  can  be  easily  found  through  an  incision 
an  inch  and  a-half  long,  curving  upward  between  the  in- 
ternal epieondylc  and  the  olecranon. 

In  the  forearm  its  course  is  indicated  by  a  line  drawn 
from  the  space  between  the  internal  epieondylc  and  the 
olecranon  to  the  radial  side  of  the  pisiform  bone.  At 
first,  it  lie-  over  the  flexor  profundi!-  beneath  the  flexor 
carpi  ulmuis.  At  the  wrisl  it  is  superficial,  and  lies  on 
the  annular  ligament  with  the  ulnar  artery  on  its  radial 
1  Brit  Med.  Journ.,  1891,  VoL  I.,  p.  752, 


MUSCULO-SPIRAL  NERVE.  229 

side.  It  is  easily  reached  at  the  wrist  by  an  incision 
about  two  inches  long  extending  upward  through  the  skin 
and  fascia  from  the  pisiform  bone.  The  incision  is 
parallel  to  and  close  to  the  radial  side  of  the  flexor  carpi 
ulnaris  tendon. 

MUSCULO-SPIRAL    NERVE. 

It  winds  around  the  humerus  in  the  musculo-spiral 
groove  between  the  internal  and  external  heads  of  the 
triceps,  and  reaches  the  outer  side  of  the  arm  at  about  the 
junction  of  the  middle  and  lower  thirds,  and  is  accom- 
panied by  the  superior  profunda  artery.  It  then  pierces 
the  external  intermuscular  septum  and  descends  in  the 
groove  between  the  brachialis  anticus  and  supinator  longus 
to  the  front  of  the  external  condyle.  At  this  point  it  is 
most  easily  found. 

Operation. — An  incision  about  three  inches  long  is  made 
at  the  upper  part  of  the  supinator  groove,  the  fascia  di- 
vided, and  the  nerve  sought  in  the  bottom  of  the  groove ; 
it  is  then  followed  upward  or  downward,  according  to  the 
circumstances  of  the  case. 

Great  Sciatic  Nerve. — An  incision  three  or  four  inches 
long  is  made  downward  from  the  gluteal  fold,  midway  be- 
tween the  tuberosity  of  the  ischium  and  the  great  tro- 
chanter. After  division  of  the  skin  and  fascia  the  lower 
border  of  the  gluteus  maximus  is  observed  and  the  ham- 
string muscles  recognized. 

The  nerve  lies  on  the  external  rotators  of  the  thigh  just 
in  front  of  and  to  the  outer  side  of  the  hamstring  muscles. 

Internal  Popliteal  Nerve. — It  is  reached  by  the  incision 
for  ligation  of  the  popliteal  artery.  It  is  superficial  to  the 
vein  and  artery  and  slightly  external. 

External  Popliteal  Nerve. — This  nerve  lies  close  behind 
and  to  the  inner  side  of  the  tendon  of  the  biceps,  and  is 
exposed  by  an  incision  two  or  three  inches  long  parallel 
to  and  close  to  the  inner  side  of  that  tendon. 

Anterior  Crural  Nerve. — A  longitudinal  incision  about 
two  inches  in  length  is  made  downward  from  Poupart's 
ligament,  about  an  inch  to  the  outer  side  of  the  femoral 


230  MISCELLANEOUS  OPERATIONS. 

artery.     The  superficial  circumflex  iliac  vessels  will  be  di- 
vided ;  the  nerve  will  be  found  close  beneath  the  fascia. 

NEURORRHAPHY. 

I.  Primary  Suture. — An  incision  is  made  in  the  course 
of  the  nerve,  exposing  it  at  the  point  of  division.  The 
ends  are  brought  together  by  a  couple  of  fine  sutures  of 
silk  or  catgut  passed  directly  through  the  substance  of  the 
nerve  or  through  the  nerve  sheath.  They  must  be  so 
placed  and  tied  as  not  to  strangulate  the  fibers. 

II.  Secondary  Suture. — A  long  incision  will  probably  be 
necessary  ;  it  should  be  made  in  the  normal  course  of  the 
nerve  and  extend  well  above  and  below  the  point  of  di- 
vision. The  trunk  of  the  nerve  should  be  sought  for  both 
above  and  below  the  cicatricial  tissue  of  the  original 
wound,  and  traced  downward  and  upward  respectively  to 
the  divided  and  separated  ends.  Such  part  of  each  end 
as  is  bulbous  or  imbedded  in  cicatricial  tissue  should  be 
cut  away  and  the  divided  surfaces  brought  into  apposition 
and  sutured.  Tension  should  be  relieved  by  freeing  the 
nerve  above  and  below  and  by  flexing  adjoining  joints. 

It  is  not  absolutely  necessary  to  success  that  the  divided 
ends  should  be  brought  close  together ;  reunion  has  taken 
place  across  gaps  of  considerable  length,  one  or  two  centime- 
ters ;  it  has  been  thought  to  be  favored  under  such  circum- 
stances by  the  presence  of  a  suture  connecting  the  two  ends. 

When  there  has  been  a  considerable  loss  of  nerve  sub- 
-t ; 1 1 )< •*',  rendering  it  impossible  to  bring  the  divided  ends 
near  together,  flaps  have  been  cut  from  the  proximal  and 
distal  stumps  and  unfolded,  and  their  extremities  united 
as  in  tenorrhaphy  (Fig.  82) ;  or  the  distal  stump  may  be 
freshened  and  then  sutured  between  the  fibers  of  a  neigh- 
boring uninjured  nerve  of  similar,  or  at  least  partly  similar, 
character. 

TENOTOMY. 
The  blade  of  a  tenotomy  knife  should  be  one  inch  long, 
it-  shank  one  and   three-quarters,  its  handle  strong  and 
marked  in  such  a  way  that  the  surgeon  can  see  at  a  glance 


TENOTOMY.  231 

in  which  direction  the  edge  of  the  blade  is  turned.  The 
blade  may  be  straight  or  curved,  it  should  be  thick  at  the 
heel,  very  narrow,  and  the  point  should  be  somewhat 
rounded  and  sharpened  from  side  to  side  like  a  wedge  or 
chisel.     (Say  re.) 

A  fold  of  skin  should  be  pinched  up  at  the  side  of  the 
tendon,  and  the  knife  entered  at  its  base,  so  that  a  con- 
tinuous track  will  not  be  left  on  its  withdrawal.  A  pre- 
liminary puncture  may  be  made  with  a  sharp-pointed  knife 
or  lancet  to  facilitate  the  entry  of  the  tenotome. 

The  knife  must  be  entered  "  on  the  flat "  and  passed 
either  under  the  tendon  or  between  it  and  the  skin  ;  its 
edge  is  then  turned  toward  the  tendon  and  the  division 
effected  with  gentle  sawing  movements,  the  thumb  being 
pressed  firmly  against  the  tendon  if  the  knife  has  been 
passed  under  it. 

During  the  entry  of  the  knife  and  the  division  of  the 
tendon  the  latter  must  be  kept  firmly  upon  the  stretch, 
and  as  soon  as  the  division  is  complete  the  knife  must  be 
turned  upon  its  side  and  withdrawn,  while  the  surgeon 
follows  its  point  with  his  thumb  or  finger  so  as  to  force 
out  any  blood  that  may  be  in  its  track  and  to  prevent  the 
entrance  of  air. 

Seal  the  wound  with  plaster  or  collodion,  and  then  bring 
the  member  into  the  desired  position. 

Tendo  Achillis. — The  knife  should  be  entered  on  the  in- 
ner side  of  the  tendon  near  its  border,  about  one  inch  above 
the  upper  surface  of  the  calcaneum.  In  this  way  the  pos- 
terior tibial  artery,  which  lies  between  the  tendon  and  the 
inner  malleolus  and  below  the  deep  fascia,  is  secured  from 
injury.  The  heel  must  be  depressed  as  much  as  possible, 
so  as  to  make  the  tendon  more  prominent  and  give  addi- 
tional security  to  the  artery. 

Tibialis  Posticus. — The  tendon  of  this  muscle  may  be 
divided  (A)  above  the  malleolus,  or  (B)  on  the  side  of  the 
foot  just  behind  its  insertion  into  the  scaphoid. 

A.  Above  the  Malleolus. — The  muscle  is  made 
tense  by  everting  the  foot ;  the  knife  is  entered  at  the  in- 
ner side  of  the  tendon  and  passed  behind  it. 


232  MIS(  'EL  L.  1 XEO  US  OPERA  TIOXS. 

B.  Ox  the  Side  of  the  Foot. — Same  position  given 
to  the  foot.  The  knife  should  be  directed  from  above 
downward  and  passed  under  the  upper  border  of  the  ten- 
don at  a  point  half  an  inch  below  and  in  front  of  the  tip 
of  the  malleolus.     Bell '  prefers  to  cut  toward  the  bone. 

Tibialis  Anticus. — Can  be  easily  made  prominent  and 
isolated. 

Peronei. — May  be  divided  at  the  posterior  face  of  the 
lower  end  of  the  fibula,  or  on  the  side  of  the  foot  below 
and  in  front  of  the  tip  of  the  outer  malleolus. 

Flexor  Tendons  at  the  Knees. — It  must  be  remembered 
that  the  external  popliteal  nerve  accompanies  the  tendon 
of  the  biceps  closely,  lying  upon  its  inner  side. 

Sterno-cleido-mastoid. — The  danger  to  be  avoided  in  this 
operation  is  that  of  injury  to  the  external  jugular  vein  at 
the  outer  border  of  the  muscle,  or  to  the  anterior  jugular 
vein  at  its  inner  border.  The  first  can  usually  be  seen 
under  the  skin  and  avoided,  the  other  leaves  the  muscle 
about  three-quarters  of  an  inch  above  the  sternum  and 
passes  backward.  The  muscle  should  be  divided  about 
half  an  inch  above  the  top  of  the  sternum,  and  most  au- 
thorities agree  in  preferring  to  divide  from  before  back- 
ward. The  knife  should  be  entered  at  the  outer  border 
of  the  muscle.  The  open  operation  is  now  generally  pre- 
ferred as  less  dangerous  and  more  likely  to  give  a  good 
result. 

TENORRHAPHY. 

Primary.  —  Performed  immediately  after  the  injury. 
The  wound,  which  is  usually  transverse,  should  be  en- 
larged by  an  incision  crossing  it  in  the  line  of  the  tendon 
and  carried  through  skin  and  fascia.  The  distal  portion 
<>f  the  tendon  can  be  made  to  appear  in  the  wound  by 
moving  its  distal  joints  in  the  direction  taken  when  its 
muscle  contracts  (e.  //.,  flexing  the  fingers  when  the  flexor 
tendon-  have  been  divided),  but  to  find  the  proximal  end 
it  i-  often  accessary  to  seek  we]]  above  the  line  of 
division,  and    it  is  therefore  well   to  expose  the  region 

1  Manual  of  Surgical  Operations,  :!<1  edition,  p.  288. 


TENOHRHAPHY. 


233 


freely.  The  divided  tendon  ends  are  drawn  into  apposi- 
tion and  stitched  together  with  fine  silk,  silkworm-gat,  or 
catgut.  The  common  forms  of  suture  are  represented  in 
Fiffs.  78-81. 


Fio.  78. 


Tenorrhaphy  by  a  suture  passed  through  the  substance  of  each  segment. 

Fig.  79. 


Tenorrhaphy.     The  tendon  ends  cut  obliquely  to  increase  the  surfaces  in  contact. 

Fl«.    80. 


Tenorrhaphy.    Showing  the  method  of  inserting  a  suture  which  does  not  readily 

pull  out. 

Ingrafting  of  portions  of  tendon  taken  from  another 
region  or  even  another  animal  has  been  performed,  and  it 
is  said  successfully.  (Bulletin  de  la  Soe.  de  Chir.,  1886, 
p.  3.57.) 


234 


MISCELLA  NEO I  rs  OPERA  TIONS. 


It  is  important  to  immobilize  the  limb  during  healing 
in  the  position  of  greatest  relaxation  of  the  sutured  tendon. 

Secondary. — Performed  after  a  considerable  interval  of 
time  has  elapsed  since  the  injury.      The  divided  tendon 


Fig.  81. 


Tenorrhaphy  by  four  ligatures  inserted  and  tied  (.1)  in  each  Stump,  and  their  free 
ends  then  uuited  (B). 

ends  will  have  to  be  sought  for  amid  cicatricial  tissue  and 
brought  into  the  best  possible  apposition.  The  ends  can 
be  split  and  lengthened,  as  shown  in  Fig.  82  ;  if  this  will 


Fig.  82. 


Tenorrhaphy  by  flaps  i"  bridge  over  a  gap  between  the  tendon  ends 


not  do,  or  if  the   proximal    end  of  the   tendon   cannot  be 
found    the    distal    end    may    be   sutured    to   a    neighboring 

tendon  having  the  same  general  anatomical  course. 

The   surface    from  which    union    is   expected  should   be 

freshened  by  .-craping. 


OSTEOTOMY, 


■j.\r> 


OSTEOTOMY. 
Osteotomy  of  the  Femur — 

I.  Through  the  Neck  (Adams's  operation),  described 
on  page  151. 

II.  Below  the  Great  Trochanter,  described  on 
page  152. 

III.  Osteotomy  of  the  Shaft  of  the  Femur. 

In  a  normal  femur  the  lower  epiphyseal  line  is  about  on 
a  level  with  the  tubercle  of  the  adductor  magnus  and  trans- 
verse in  direction.     But  in  cases  of  genu   valgum  it   is 

Fig.  83. 


Frontal  section  through  the  lower  end  of  the  femur  in  a  case  of  severe  genu  val- 
gum. A.  Epiphyseal  line.  B.  Transverse  line  drawn  through  the  adductor  tuber- 
cle.    C.  Line  of  bone  section  in  Macewen's  operation. 


oblique  and  parallel  with  the  articular  surface.  This  is 
due  to  the  fact  that  genu  valgum  is  produced  by  an  over- 
growth of  the  diaphysis  of  the  femur  and  not  of  the  epi- 
physis (Fig.  83). 

Osteotomy  of  the  Shaft  of  the  Femur  from  the  Outer  Side. 
— The  knee  is  partially  flexed  and  supported  on  a  sand- 
bag beneath  its  inner  surface.  A  longitudinal  incision 
down  to  the  bone  is  made  on  the  outer  aspect  of  the  thigh 
about   two  inches  above  the  top  of  the  external  condyle 


236  MISCELLANEOUS  OPERATIONS. 

and  well  in  front  of  the  tendon  of  the  biceps.  The  peri- 
osteum is  divided  transversely,  and  stripped  back  suffici- 
ently to  expose  the  base  of  the  wedge  of  bone  that  is  to  be 
removed,  and  then  with  a  chisel  this  wedge  is  cut  away 
piecemeal,  care  being  taken  throughout  to  remove  the  cor- 
responding part  of  the  anterior  and  posterior  shell  of  the 
bone.  The  chisel  may  be  used  until  the  division  is  com- 
plete, or  the  last  part  may  be  broken  by  forcibly  adduct- 
ing  the  fully  extended  leg.  At  the  conclusion  of  the  opera- 
tion the  wound  is  closed  and  dressed  antiseptically,  and  the 
limb  is  immobilized  in  the  corrected — straight — position. 

Supra-condyloid  Osteotomy  of  the  Femur. — The  hip  and 
knee  are  flexed,  and  the  thigh  supported  on  its  outer  side. 
A  longitudinal  incision  two  or  three  inches  long  is  made 
on  the  inner  side  of  the  thigh  close  above  the  condyle  and 
carried  through  the  fascia,  the  fibers  of  the  vastus  interims 
are  drawn  forward  and  the  bone  exposed  at  their  attach- 
ment. The  periosteum  is  divided  and  a  wedge  of  bone 
removed  as  described  in  the  preceding  section.  After  ar- 
rest of  the  bleeding,  which  may  be  quite  free  at  the  lower 
angle,  the  wound  is  closed  and  the  limb  immobilized  with 
plaster  of  Paris. 

Some  prefer,  in  both  these  operations,  simply  to  divide 
the  bone  by  driving  the  chisel  straight  across,  without 
removing  a  wedge  of  bone.     (MacEwen.) 

OSTEOTOMY  FOR  HALLUX  VALGUS. 

A  longitudinal  incision  about  two  inches  long  is  carried 
down  to  the  periosteum  on  the  mesial  surface  of  the  lower 
part  of  the  first  metatarsal  bone  opening  the  joint.  The 
lioiic  is  divided  and  a  wedge  of  tissue  removed  from  it 
sufficient  to  allow  the  toe  to  be  brought  into  line.  Usu- 
ally the  head  of  the  metatarsal  bone  is  deformed  by  over- 
growth on  its  mesial  side,  in  which  case  it  should  be  freely 
cut  away.  No  troublesome  limitation  of  motion  is  to  be 
feared  if  infection  of  the  wound  is  avoided. 


CUNEIFORM  OSTEOTOMY.  237 

CUNEIFORM  OSTEOTOMY  FOR  TALIPES  EQUINO- 
VARUS. 

A  horizontal  incision  is  made  along  the  outer  side  of 
the  foot  from  about  the  center  of  the  anterior  portion  of 
the  outer  surface  of  the  os  calcis  across  the  cuboid  to  the 
base  of  the  fifth  metatarsal  bone.  If  necessary  this  is 
joined  at  its  center  by  a  liberating  incision  passing  per- 
pendicularly to  the  horizontal  incision  across  the  outer 
surface  and  dorsum  of  the  foot  to  or  over  the  scaphoid. 

The  base  of  the  wedge  of  bone  to  be  removed  will  con- 
sist mainly  of  the  cuboid  with  portions  of  the  os  calcis,  the 
astragalus,  and  perhaps  a  part  of  the  external  cuneiform 
and  base  of  the  fifth  metatarsal.  The  apex  will  corre- 
spond to  a  point  on  the  inner  surface  of  the  scaphoid. 
The  amount  of  bone  which  may  need  removal  will  of 
course  depend  upon  the  extent  of  the  deformity,  but  in 
extreme  cases  it  may  include  portions  of  all  the  tarsal  and 
some  of  the  metatarsal  bones.  In  every  case  the  cuboid 
will  form  a  large  proportion  of  the  wedge. 

With  a  blunt  periosteal  elevator  all  the  soft  parts  are 
detached  from  the  bone  that  is  to  be  removed  ;  the  peronsei 
tendons  are  retracted  or  protected  ;  a  thin  blunt  elevator 
may  be  pushed  close  under  the  plantar  surface  of  the 
bones  to  protect  the  soft  parts  of  the  sole.  The  chisel  is 
then  driven  in  for  the  first  bone  cut,  generally  at  the  an- 
terior end  of  the  outer  surface  of  the  cuboid.  It  is  di- 
rected toward  the  lower  part  of  the  scaphoid  tubercle. 
The  second  line  of  bony  division  will  usually  need  to  pass 
just  behind  the  anterior  articular  surface  of  the  os  calcis 
and  through  the  neck  of  the  astragalus  to  meet  the  first 
incision  at  the  scaphoid  tubercle.  This  wedge  of  bone  is 
then  pried  or  wrenched  out  entire,  while  any  remaining 
attachments  beneath  are  severed  with  blunt-pointed  scissors 
or  a  knife  kept  close  to  the  bone.  If  then  it  is  found  that 
the  foot  cannot  be  made  to  assume  the  proper  position 
without  tension  another  slice  of  bone  is  chiseled  olf,  espe- 
cially toward  the  apex  of  the  wedge.  This  may  be  sup- 
plemented by  tenotomy  of  any  resisting  tendons.     The 


238  MISCELLANEOUS  OPERATIONS. 

thickened  epidermis  and  the  bursa  usually  found  over  the 
site  <>f  the  cuboid  may  be  excised  if  there  is  found  to  be  a 
redundancy  of  skin  after  straightening  the  foot. 

No  wiring  of  the  bones  is  necessary.  The  soft  parts 
are  sutured  and  the  wound  dressed  antiseptically.  Any 
oozing  which  may  subsequently  occur  will  dry  and  make 
of  a  simple  antiseptic  dressing  a  very  efficient  splint. 

Of  the  great  number  of  other  operative  procedures 
which  may  be  used  singly  or  in  combination  with  each 
other  or  with  cuneiform  osteotomy  for  correcting  pes 
varus  or  equino-varus  mention  should  be  made  of  tenot- 
omy of  resisting  tendons  (7.  v.),  extirpation  of  the  astraga- 
lus (7.  r.),  extirpation  of  the  cuboid  or  of  several  tarsal 
bones  simultaneously,  linear  osteotomy  of  the  tibia  and 
fibula  just  above  ankle-joint  (7.  v.),  and  Phelps's  '  opera- 
tion. The  latter,  although  not  an  osteotomy,  will  be  de- 
scribed here.2 

It  is  extensively  used  for  remedying  talipes  equino- 
varus,  and  consists  in  a  simple  division  of  all  structures 
which  resist  correction  of  the  deformity.  The  tendo 
Achillis  is  first  divided  subcutaneously ;  then,  while  the 
foot  is  flexed  dorsally,  abducted  and  everted,  an  incision 
through  the  skin  is  made  from  just  in  front  of  the  in- 
ternal malleolus  vertically  downward  across  the  inner 
third  of  the  sole  of  the  foot.  After  making  the  parts 
tense  the  tibialis  anticus  and  posticus,  the  deltoid  liga- 
ment, pari  of  the  abductor  pollicis,  the  plantar  fascia,  and 
the  flexor  brevis  and  longus  digitorum  are  severed  as  en- 
countered in  the  wound.  The  plantar  vessels  and  nerves 
.in  spared  if  possible,  although  their  internal  branches 
have  been  cut  without  bad  effect. 

A-  each  structure  is  divided  an  attempt  is  made  forcibly 
to  place  the  foot  in  its  proper  position.  Phelps  employs 
a  powerful  system  of  Levers,  and  ruptures  any  resisting 
ligamentary  or  fibrous  bands.  When  all  opposition  has 
been  properly  overcome  the  anterior  segment  of  the  foot 

1  New  England  Medical  Monthly,  L891. 

'This  operation  is  discussed  and  the  results  detailed  in  Transactions 
Am.  Orthopaedic  Asso>,  Vol.  \  II.,  p.  43i 


CUNEIFORM  OSTEOTOMY.  239 

can  he  bent  backward  in  overcorrection,  thus  probably 
opening  the  astragalo-scaphoid  and  calcaneo-cuboid  joints. 

Only  in  about  10  per  cent,  of  all  cases,  according  to  the 
originator  of  this  operation,  will  osteotomy  be  required. 
When  necessary  to  correct  the  deformity  after  all  the  re- 
sisting soft  parts  have  been  cut,  the  neck  of  the  astragalus 
should  be  divided  from  the  inside  ;  then,  if  this  is  insuf- 
ficient, a  wedge  may  be  removed  from  the  anterior  portion 
of  the  os  caleis  ;  the  base  of  the  wedge  lies  externally,  the 
apex  where  the  neck  of  the  astragalus  has  been  divided. 
The  open  wound  on  the  inner  side  of  the  foot  is  either 
lightly  packed  with  iodoform  gauze  or  allowed  to  heal 
under  a  moist  blood  clot ;  over  this  an  antiseptic  dressing 
is  applied  and  encased  in  plaster  of  Paris,  the  foot  being 
maintained  in  a  slightly  overcorrected  position. 

CUNEIFORM    OSTEOTOMY    FOR    TALIPES    EQUINUS. 

Two  incisions  are  employed. 

The  inner  incision  passes  along  the  mesial  surface  of 
the  neck  of  the  astragalus  and  across  the  scaphoid  to  ter- 
minate at  the  internal  cuneiform  bone.  The  external  in- 
cision extends  from  the  middle  of  the  anterior  portion  of 
the  outer  surface  of  the  os  caleis  across  the  cuboid  to  ter- 
minate at  the  base  of  the  fifth  metatarsal  bone.  The  soft 
parts  are  raised  from  the  dorsum  of  the  foot,  and  a  flat 
periosteal  elevator  can  be  passed  close  beneath  the  plantar 
surface  of  the  bones  to  protect  the  soft  parts  of  the  sole. 
A  wedge  is  then  cut  from  the  tarsal  bones  with  the  base 
on  the  dorsum  of  the  foot.  Its  extent  will  depend  on  the 
degree  of  the  deformity,  but  the  apex  must  reach  to  the 
plantar  surface  of  the  bones.  A  metacarpal  saw  or  chisel 
can  be  used. 

The  wedge,  which  may  be  extracted  in  one  piece,  will 
consist  chiefly  of  the  scaphoid  and  cuboid  bones,  with  per- 
haps portions  of  the  anterior  extremities  of  the  astragalus 
and  os  caleis.  At  the  close  of  the  operation  the  soft  parts 
which  have  been  divided  are  sutured  and  the  foot  immobi- 
lized with  the  bones  in  apposition. 


240  MISCELLANEOUS  OPERATIONS. 

CUNEIFORM  OSTEOTOMY  FOR  TALIPES  VALGUS 
OR  PES  PLANUS. 

An  incision  is  begun  just  below  the  apex  of  the  internal 
malleolus  and  carried  forward  two  inches.  The  soft  parts 
are  carefully  raised  from  the  inner  and  under  surface  of 
the  astragalus  and  a  suitable  wedge  removed  from  it. 
The  base  of  the  wedge  should  lie  below  and  include  either 
the  neck  alone  of  the  astragalus  or  the  articular  surfaces 
of  the  astragalus  and  scaphoid. 

OPERATIONS  FOR  UNUNITED  FRACTURE. 

The  aim  of  the  operative  treatment  for  old  ununited 
fracture  is  to  place  the  freshened  ends  of  the  bone  in  con- 
tact and  to  keep  them  immobilized  in  this  position. 

A  free  incision  is  necessary.  In  general  it  should  be 
in  the  long  axis  of  the  limb,  and  so  placed  as  to  reach  the 
point  of  fracture  by  the  shortest  route  with  the  least  pos- 
sible damage  to  nerves  and  vessels.  Any  tissue  which 
may  be  found  intervening  between  the  ends  of  the  bone  is 
dissected  out  and  removed.  It  will  often  be  found  advan- 
tageous to  protrude  the  ends  of  the  bone  through  the 
wound.  The  extremity  of  each  fragment  is  then  pared  off 
with  the  rongeur  or  chisel  till  fresh  cancellous  tissue  is 
exposed  over  the  whole  section  of  the  shaft  and  the  two 
surfaces  can  be  opposed  throughout.  If  the  fragments 
override,  enough  bone  is  removed  to  allow  the  ends  to  be 
brought  into  apposition  without  tension.  Wiring  is  to  be 
condemned  as  superfluous.  It  will  seldom  be  found  nec- 
essary to  do  more  than  freshen  the  ends  of  bone  and  main- 
tain them  in  quiet  apposition  with  a  suitable  splint.  If 
there  is  any  doubt  about  their  remaining  in  this  position 
while  the  splint  is  applied  and  subsequently,  it  is  better  to 
drill  a  small  hole  about  half  an  inch  from  the  fracture  line 
on  each  side  and  tie  the  ends  together  with  a  piece  of 
kangaroo-tendon  or  stout  chromicized  catgul  or  silk.  If 
the  limb  is  handled  carefully  this  will  keep  the  bones  in 

contact  and  prevent  the  interposition  of  soft  parts  till  the 
Limb  has  been  immobilized.      In  addition  to  this  the  peri- 


SUTURE  OF  THE  PATELLA.  241 

osteins  is  as  far  as  possible  preserved,  and  any  divided 
soft  parts  in  the  neighborhood  should  be  placed  in  proper 
position  and  reunited.  This  will  serve  as  a  sling  for  the 
bones  to  rest  in.  The  wound  is  then  closed  layer  by  layer 
and  dressed  antiseptically,  with  provision  for  temporary 
drainage.  If  pegs  or  nails  have  been  used  they  should 
reach  to  the  skin  surface  and  be  included  in  the  dressings, 
and  should  be  removed  in  about  a  week. 

SUTURE  OF  THE  PATELLA. 

Fig.  84. 


Mediate  suture  for  fracture  of  tlie  patella. 


Mediate  Silk  Suture.  (Fig.  84.) — A  longitudinal  median 
incision  is  made  extending  well  above  and  below  the  frac- 
ture. Clots  are  washed  from  the  joint  with  salt  solution, 
and  the  fibro-periosteal  fringe  lifted  up  if  one  has  formed. 
Then,  with  a  full-curved  needle,  a  stout  silk  ligature  is 
passed  transversely  through  the  ligamentum  patella?  close 
to  the  apex  of  the  patella,  then  transversely  in  the  opposite 
direction  through  the  tendon  of  the  quadriceps  close  to  its 
insertion,  and  then  drawn  tight  and  tied  while  the  frag- 
ments are  held  together.  One  or  two  catgut  sutures  may 
be  placed  in  the  torn  capsule  on  each  side.  The  incision 
is  then  closed  without  drainage. 

Many  other  more  or  less  complicated  methods  of  hold- 
ing the  fragments  together  have  been  devised  ;  this  one  is 
as  simple  as  any,  and  has  proved  to  be  efficient  and  safe  in 
about  one  hundred  personal  eases.  In  a  number  of  cases 
catgut  sutures  passed  through  the  fibro-periosteum  near  the 
edge  of  the  fracture  have  given  good  results.  A  transverse 
16 


242  MISCELLANEOUS  OPERATIONS. 

or  curved  incision  permits  more  exact  suturing  of  the  torn 
capsule  but  divides  several  large  veins  and  is  more  likely 
to  become  adherent  along  the  line  of  fracture.  Wire 
sutures  are,  in  my  judgment,  to  be  condemned  as  unneces- 
sary and  as  unduly  complicating  the  operation  and  the 
repair. 

OPERATION  FOR  NON-UNION   AFTER  FRACTURE    OF 
THE  OLECRANON  PROCESS. 

A  median  longitudinal  incision  is  made  over  the  poste- 
rior surface  of  the  olecranon  and  ulna,  exposing  the  bone 
at  the  point  of  fracture.  The  interposed  fibrous  tissue  is 
cleared  away  and  the  ends  of  the  fragments  freshened. 
The  olecranon  and  ulna  are  drilled  obliquely  without  per- 
forating the  articular  surface.  The  holes  start  on  the  pos- 
terior surface  about  one-quarter  of  an  inch  from  the  edge 
of  the  fracture  and  terminate  in  the  fractured  surface. 

The  fragments  are  drawn  together  with  a  silk  suture 
and  the  limb  immobilized  by  an  antiseptic  dressing  in 
complete  extension. 

Mediate  suture,  with  silk  passed  through  the  tendon  of 
the  triceps  and  a  hole  drilled  transversely  through  the 
shaft  of  the  ulna  half  an  inch  or  more  below  the  fracture 
or  even  through  the  periosteum,  has  given  me  good  results 
and  i-  probably  to  be  preferred  to  direct  suturing. 

LAMINECTOMY.1 

An  incision  five  or  six  inches  long  is  made  in  the 
median  line  over  the  summit  of  the  spinous  processes  in 
question,  and  quickly  deepened  close  to  one  side  of  them 
till  the  lamina'  are  exposed,  from  which  the  periosteum 
with  the  attached  muscles  is  raised  with  an  elevator  out  to 
the  articular  and  transverse  processes.  The  bases  of  the 
spinous  processes  are  next  cut  through  with  a  chisel  or 
bone  forceps,  and  the  opposite  laminae  \'\%cc(\  in  the  same 
way  of  periosteum  and  muscle,  without  disturbing  the 
muscular    attachments  of  the  spinous  processes. 

'Thorburn:  Surg.  of  spin.  Cord.  Lloyd:  Amer.  Journ.  Med. 
Sciences,  1891,  Vol.  102,  p.  •_'•"». 


THIERSCH'S  SKIN  GRAFTING.  243 

Some  operators  prefer  to  make  two  parallel  incisions  on 
each  side  of  the  spinous  processes,  which  are  then  excised, 
and  Horslcy,  to  better  expose  the  laminae,  divides  the 
lumbar  aponeurosis  and  muscles  at  right  angles  to  the 
middle  of  the  longitudinal  incisions.  The  sides  of  the 
wound  are  well  retracted  and  the  laminae  are  divided  close 
to  the  transverse  processes  with  a  rongeur,  bone  forceps,  or 
chisel,  and  the  posterior  arch  thus  removed. 

If  the  trouble  is  not  then  apparent,  before  opening  the 
dura  a  probe  should  be  passed  up  and  down  to  make  sure 
that  the  cord  has  been  exposed  in  the  proper  locality.  If 
then  it  is  considered  necessary,  the  dura  is  pinched  up 
and  opened  longitudinally  in  the  median  line  behind. 

Subsequently  the  wound  in  the  dura  is  closed  with  fine 
catgut  or  silk  sutures  and  the  overlying  parts  brought 
together  by  buried  and  superficial  sutures  over  a  drainage- 
tube  placed  in  the  deepest  portion  of  the  wound. 


MISCELLANEOUS    OPERATIONS. 

THIERSCH'S    SKIN   GRAFTING. 

The  wound  to  which  the  graft  is  to  be  applied  must  be 
fresh,  clean,  dry  and  perfectly  aseptic.  If  it  is  already  a 
granulating  surface  all  pus  must  be  carefully  scrubbed 
away  and  the  granulations  freely  shaved  away  with  a 
knife.  It  is  then  thoroughly  washed  with  a  sterilized 
salt  solution  (about  3j  of  common  salt  to  Oj  of  water). 
Bleeding  is  checked  by  the  pressure  of  a  sterilized  com- 
press maintained  until  the  grafts  are  ready  to  be  applied, 
in  order  to  preserve  the  asepsis  and  to  prevent  the  forma- 
tion of  clots  of  blood  which  would  separate  the  graft 
from  contact  with  the  raw  surface. 

The  graft  is  commonly  taken  from  the  front  or  outer 
surface  of  the  thigh,  as  this  presents  a  conveniently  broad 
surface  of  skin  of  the  requisite  thickness.  It  must  be 
previously  shaved  and  scrubbed,  then  rinsed  off  with  al- 
cohol and  finally  with  sterilized  water.  The  skin  of  the 
thigh  is  drawn  tense  and  Mat  by  one  hand  grasping  the 


244  MISl  'EL  LANEO  US  OPERA  T10NS, 

thigli  just  above  the  knee  and  pulling  down.  W i t ] i  the 
other  hand  a  broad-bladed  razor3  ground  flat  on  the  sur- 
face held  next  the  thigh,  is  drawn  downward  toward  the 
knee  by  quick  sawing  motions  through  the  skin  parallel 
to  and  just  beneath  its  surface.  The  cutting  must  be 
done  with  accuracy  and  the  razor's  cdov  must  lie  always 
in  the  papillary  layer  of  the  skin.  Practically  it  must 
pass  just  deep  enough  to  leave  the  cut  surface  studded 
with  minute  specks  of  blood  which  do  not  coalesce  for  an 
appreciable  length  of  time.  If  the  knife  exposes  any 
particle  of  the  subcutaneous  fat  the  corresponding  part  of 
the  intended  graft  must  be  rejected.  The  sterilized  salt 
solution  is  allowed  to  trickle  on  the  skin  immediately  in 
front  of  the  advancing  razor-edge  and  serves  to  float  the 
graft  up  into  the  concavity  on  the  anterior  surface  of  the 
razor  and  with  a  little  practice  facilitates  the  cutting.  A 
strip  six  or  eight  inches  long  and  one  and  a-half  or  two 
inches  wide  can  be  cut  and  retained  on  a  broad  blade. 
The  attached  end  of  the  graft  is  severed  with  scissors. 
The  graft  is  then  immediately  unfolded  on  the  prepared 
wound  surface  by  retaining  the  whole  width  of  the  free 
end  against  one  margin  of  the  area  to  be  covered  and 
gently  withdrawing  the  razor  while  its  edge  is  kept  con- 
stantlv  in  contact  with  the  wound  surface. 

If  any  portions  of  the  graft  get  turned  over  so  as  to  op- 
pose the  epidermic  layer  to  the  wound  surface,  they  must 
be  carefully  unfolded.  In  addition  all  air  bubbles  must 
be  pressed  out  toward  the  edges;  and,  in  short,  every 
part  of  the  freshly  cut  surface  of  the  graft  must  be 
Wrought  into  accurate  contact  with  the  underlying  raw 
surface  which  is  to  be  covered. 

Successive  grafts  are  cut  and  applied  until  the  entire 
Mii-face  is  covered. 

The  grafts  are  then  covered  completely  with  strips  of 
sterilized  rubber  tissue  about  an  inch  wide  (after  rinsing 
them  in  the  sterilized  salt  solution),  placed  side  by  side 
with  the  edges  slightly  overlapping. 

This  arrangement  permits  drainage  and  allows  the  graft 
to   be   kept   damp  with   the   next    applied   sterilized    com- 


SEPARATION   OF   WEB-FINQERS. 


245 


presses,  wrung'  out  in  either  the  sterilized  salt  solution  or 
a  sterilized  saturated  solution  of  boric  acid. 

The  compresses  are  covered  with  a  sheet  of  sterilized 
rubber  tissue  to  prevent  drying.  This  dressing  must  be 
v<rv  carefully  bandaged  in  place  with  even  pressure  and 
without  disturbing  the  grafts.  From  time  to  time,  till  it 
is  removed  at  the  end  of  tive  days,  it  must  be  moistened 
with  the  sterilized  salt  or  boric  solution. 


SEPARATION   OF   WEB-FINGERS. 

Experience  has  shown  that  simple  division  of  the  mem- 
brane uniting  the  two  fingers  is  insufficient,  because,  re- 
union, beginning  at  the  angle,  is  certain  to  extend  over  the 
whole  length  of  the  incision.  A  simple  way  of  overcom- 
ing this  difficulty  is  to  pass  a  leaden  or  silver  wire  through 
a  puncture  made  at  the  interdigital  angle,  keep  it  there 
until  cicatrization  has  taken  place  around  it,  as  around  an 
ear-ring,  and  then  divide  the  membrane.  The  angle  being 
already  cicatrized,  the  lateral  wounds  heal  separately. 


Fig.  85. 


Web  fingers 


Another  plan  is  to  mark  out  a  palmar  and  a  dorsal 
triangular  flap  at  the  interdigital  angle,  its  apex  turned 
toward  the  ends  of  the  fingers  (Fig.  85,  A),  then  to  split 
the  remainder  of  the  membrane  longitudinally,  pare  off 
the  ends  of  the  triangular  flaps,  and  unite  them   in   the 


246 


.1/ is(  el l . i M-:< >rs  oi >i:n  i  ri oxs. 


intercligital  angle.      By  this  means  a  bridge  of  integument 
is  formed  which  prevents  reunion  of  the  sides. 

These  two  methods  answer  very  well  when  there  is  a 
distinct  interdigital  membrane,  but  some  other  is  required 
when  the  fingers  are  closely  approximated.  The  one  which 
yields  the  best  results  is  represented  in  Fig.  85,  B,  and 
Fig.    8b\     A   rectangular  flap   is   dissected   up  from   the 


Fig.  86. 


•  i - 1 1 1 : 1 1  i . > ■  i  and  adjustment  of  Baps  in  operation  for  web-fingers. 


dorsum  of  one  ringer,  and  a  similar  flap  from  the  palmar 
surface  of  the  other  finger,  each  being  left  adherent  by  its 
long  side.  The  ringers  are  then  separated  and  each  flap 
turned  in  to  cover  one  of  the  raw  surfaces. 


CICATRICIAL    FLEXION   OF   THE    PHALANGES. 

The  cicatrix  must  be  thoroughly  divided  to  allow  com- 
plete extension,  and  then  if  skin  flaps  can  be  obtained 
from  the  sides  they  may  be  turned  in  to  cover  the  palmar 
surface  opposite  the  joints.  In  dissecting  up  the  flaps 
care  musl  !><■  taken  not  to  go  deeply  enough  to  involve 
tin-  artery  which  runs  along  the  side,  otherwise  the  end  of 
the  finger  may  slough. 

Instead  of  -mall  lateral  flaps  lor  the  flexures  of  the 
joints  the  skin  covering  the  sides  of  the  finger  may  be 
mobilized  by  lateral  or  dorsal  Longitudinal  incisions  and 
broughl  together  in  the  median  line  of  the  palmar  surface, 
tli<-  ii:i|>-  created  on  the  sides  by  their  removal  being  left 
to  Inal  bv  Granulation. 


INGROWN   TOENAIL. 


247 


DUPUYTREN'S   CONTRACTION  OF  THE  FINGERS. 

Open  Method. — A  Longitudinal  incision  is  made  through 
the  skin  along  the  entire  length  of  the  constricting  band, 
and  crossed  at  each  end  by  a  transverse  incision.  The 
flaps  thus  marked  out  are  dissected  up  from  the  aponeu- 
rosis, which  is  then  divided  transversely  or  excised. 

Resultant  gaps  in  the  skin  should  be  closed  by  flaps  or 
skin  grafts. 

INGROWN   TOENAIL. 

The  base  of  the  toe  is  constricted  with  a  rubber  tourni- 
quet and  a  few  minims  of  a  2  per  cent,  solution  of  cocaine 
injected  on  the  sides  and  dorsum.  The  nail  is  then  torn 
out  (in  all  cases)  with  forceps,  one  blade  of  which  is 
pushed  up  under  it  to  free  it  from  the  matrix. 


Fig.  87. 


ingrown  toenail.  A.  A,  B.  I>.  C,  flap  operations  (parts  removed  shown  in  B.  A'. 
B',  r',  |)').  B.  R,  I)',  s.  wedge  operation— M',  N',  showing  part  removed  In-  Cot- 
ting's  operation. 

I.  A  rectangular  Hap,  D,  E,  F,  B  (Fig.' 87,  A),  about 
one-quarter  of  an  inch  square,  is  made  and  reflected.  The 
strip  of  matrix  underlying  it  (Fig.  87,  A,  B,  D,  (')  and 
the  corresponding  part  of  the  nail  in  front,  is  then  thor- 
oughly dissected  off,  care  being  taken  to  carry  the  dissec- 
tion entirely  beyond  the  base  and  side.  The  flap  is  next 
replaced  and  secured  and  a  light  dry  dressing  applied. 


248  MISCELLANEOUS  OPERATIONS. 

IT.  The  exuberant  tissue  and  adjoining  skin  is  pared  off 
close  up  to  the  margin  of  the  nail  and  matrix  (M\  X'). 
The  resulting  wound  is  left  to  close  by  granulation. 
(Cotting.)     (Fig.  87,  B,  M'3  X'.) 

HI.  In  certain  slight  eases  a  wedge-shaped  piece  can 
lie  excised  from  the  side  of  the  toe,  and  by  closing  this 
gap  with  sutures  the  irritated  part  is  drawn  away  from  the 
nail.     (R,  S,  D',  Fig.  87,  B.) 

THE    OPERATIVE    TREATMENT    OF    DISEASED   CER- 
VICAL  GLANDS. 

The  operations  required  in  the  treatment  of  diseased 
cervical  glands  comprise  opening  abscesses,  scraping  and 
slitting  up  sinuses,  and  partial  or  complete  removal  of  the 
enlarged  lymph  nodes.  AVhen  the  latter  have  not  become 
matted  together  into  an  indistinct  mass  by  inflammatory 
processes — in  other  words,  when  the  glands  can  be  felt  as 
rounded,  more  or  less  movable  tumors,  each  can  be 
readily  turned  out  after  it  has  been  clearly  reached  and 
exposed,  but  it  is  essential  to  this  ease  of  execution  that 
the  dissection  should  pass  entirely  through  the  overlying 
connective  tissue  and  expose  the  smooth,  glistening  sur- 
face of  the  gland. 

When  the  parts  are  matted  together  the  internal  jugular 
should  first  be  sought  for  and  clearly  exposed  above  or 
below  the  mass  in  order  that  in  dissecting  away  the  mass 
of  degenerated  glands  and  infiltrated  tissue  about  them 
the  position  of  the  vein  may  be  accurately  known. 

Removal  is  ordinarily  accomplished  through  a  more  or 
less  longitudinal  incision  which  follows  the  general  direc- 
tion of  the  underlying  structures,  and  is  placed  over  the 
mosl  prominent  part  of  the  tumefaction.  This  is  gener- 
ally along  the  anterior  or  posterior  border  of  the  sterno- 
mastoid  muscle  ;  occasionally  it  may  be  necessary  to  make 
it  along  Dearly  the  whole  length  of  both  borders  to  obtain 
sufficiently  lice  access  to  all  the  glands.  The  incision 
1 1 1 1 1 - 1  lie  lon^r  enough  jo  give  a  clear  view  of  each  struc- 
ture as  it  is  encountered,  and  to  permit  of  ready  control 
of  the  hemorrhage. 


DISEASED  <  'ER  VI< *  1 1,   a  L.  1 NDS. 


249 


The  difficulties  attending  a  thorough  removal  of  all  dis- 
eased parts  by  even  a  double  longitudinal  incision  are  so 
great  that  Dr.  Hartley,  of  New  York,  has  devised  an 
operation  in  which  cutaneous  flaps  arc  raised  from  the 
surface  of  the  tumor.  At  first  sight  it  appears  unneces- 
sarily severe,  but  the  results  hitherto  have  been  excellent, 
and  the  scarring  is  not  so  noticeable  as  to  offset  the  great 
advantages  gained  by  a  complete  exposure  of  all  the 
important  parts  which  are  in  close  relationship  with  the 
enlarged  glands. 

The  incision  is  S-shaped  (Fig.  88),  and  involves  only 
the  skin,  subcutaneous  tissue,  and  fascia  ;  starting  below 
the  chin  it   passes  in  a  curve  downward  and  backward  to 

Fig.  88. 


B,  C,  D.   Hartley's  incision  for  the  removal  of  enlarged  cervical  glands.    A.  Point 
where  the  sterno-mastoid  is  divided. 


the  hyoid  bone,  then  up  behind  the  angle  of  the  jaw  to 
near  the  lobule  of  the  car,  whence   it  sweeps  down   along 


251 1  M  rSt  'EL  L .  1  NEt  >  I 'S  OPERA  TIONS. 

the  anterior  border  of  the  trapezius,  forward  over  the 
sterno-mastoid,  and  downward  and  backward  again  to 
terminate  above  the  middle  of  the  clavicle.  The  flaps 
thus  formed  are  dissected  up,  exposing  nearly  the  whole 
length  of  the  sterno-mastoid,  and  the  latter  is  cut  trans- 
versely near  its  center  and  the  ends  reflected,  care  being 
taken  not  to  injure  the  spinal  accessory  nerve  above.  The 
point  where  the  muscle  is  divided  must  not  be  in  the  line 
of  the  cutaneous  incision,  but  under  the  middle  of  one  of 
the  flaps,  preferably  the  upper.  The  great  vessels  are 
thus  exposed  from  the  mastoid  process  to  the  clavicle,  and 
the  operator  can  excise  the  adherent  and  diseased  glands 
and  avoid  injury  to  the  adjacent  important  structure-. 

At  the  close  of  the  operation  the  divided  ends  of  the 
sterno-mastoid  are  united  with  catgut,  the  flaps  replaced 
and  loosely  sutured  in  position,  and  drainage  provided  for 
in  the  most  dependent  angles. 

This  large  incision  is  only  used  when  the  glands  in  the 
superior  and  inferior  carotid  and  submaxillary  triangles 
are  involved  simultaneously.  For  less  extensive  disease 
the  upper  or  lower  flap  may  be  employed  alone,  or  one 
may  be  fashioned  with  a  pedicle  in  a  position  the  reverse 
of  that  shown  in  the  figure.  The  incision  for  a  single  flap 
should  approximately  correspond  to  the  circumference  of 
the  tumor,  which  is  then  exposed  in  its  entirety  by  di- 
vision of  the  sterno-mastoid  below  the  joint  where  it  is 
entered  by  the  spinal  accessory  nerve.  The  flap  consists 
of  skin,  subcutaneous  tissue,  platysma,  and  fascia,  and 
after  reflecting  it  the  muscle  is  always  cut  beneath  the 
center  of  the  flap,  and  not  in  the  line  of  the  cutaneous  in- 
cision. 


PART  VI. 

PLASTIC   OPERATIONS   ON   THE    FACE. 


Plastic  operations  are  required  for  the  relief  of  eon- 
genital  defects  or  for  the  restoration  of  parts  lost  by  dis- 
ease' or  injury.  The  methods  most  commonly  employed 
are  of  two  kinds  : 

1.  By  Approximation  op  the  Edges. — This  is  ap- 
plicable to  eases  in  which  the  loss  of  tissue  is  not  great 
and  the  adjoining  parts  are  supple.  The  edges  of  the  gap 
are  simply  pared  and  brought  together.  It  is  sometimes 
necessary  to  make  "liberating  incisions"  on  one  or  both 
-ides  for  the  relief  of  tension. 

2.  By  Transfer  of  a  Flap. — A  Hap  of  suitable 
shape  and  size  is  dissected  up  and  transferred,  by  turning 
it  about  its  base,  to  the  place  where  it  is  needed,  its  vital- 
ity being  insured  by  the  preservation  of  its  base  or  ped- 
icle. This  method  admits  of  a  great  variety  of  modifica- 
tions in  its  details,  from  a  simple  sliding  of  a  skin  flap, 
which  differs  but  slightlv  from  the  method  by  approxima- 
tion, to  the  transfer  of  skin,  muscle  and  bone,  or  the  tak- 
ing of  the  flap  from  another  limb  or  individual. 

The  names  Indian,  Italian,  French  and  German  methods 
have  been  given  to  the  different  varieties,  but  Verneuil  ' 
has  pointed  out  the  impropriety  of  continuing  to  employ 
them,  especially  since  at  least  two  of  them,  the  French 
and  German,  have  their  origin  in  an  oversensitive  patriot- 
ism not  mindful  enough  of  the  actual  facts.  The  Indian 
and  Italian  methods  were  first  employed  for  the  restora- 
tion of  the  nose  ;  in  the  former  a  flap  was  taken  from  the 

1  M£moires  de  Chirurgie,  Vol.  I.     Chirurgie  R£paratrice,  \>.  401. 

251 


252  PLASTIC  OPERATIONS  ON   THE  FACE. 

forehead  and  brought  down  by  twisting-  the  pedicle  which 
occupied  the  space  between  the  eyebrows.     The  term  is 

now  applied  to  any  operation  in  which  the  Hap  is  made 
with  a  long  pedicle  situated  at  sonic  distance  from  the 
space  which  the  flap  is  to  cover  and  in  which  also  the 
flap  is  brought  into  place  by  rotation  over  a  greater  or 
less  arc  described  about  the  base  of  the  pedicle  as  a  cen- 
ter (see  Fig.  115). 

In  the  Italian  method  the  flap  is  taken  from  a  distant 
part  of  the  body,  as  in  restoration  of  the  nose  by  a  flap 
taken  from  the  arm  (Fig.  117).  Tagliacozzi,  of  Bologna, 
the  originator  of  this  method,  allowed  the  flap  to  suppurate 
for  a  few  days,  so  as  to  increase  its  thickness,  before  fas- 
tening it  in  its  new  situation.  Graefe  sought  for  primary 
union,  and  gave,  rather  pompously,  the  name  German 
method  to  this  modification,  ignorant  of  the  fact  that  it  had 
been  suggested  more  than  a  century  before  by  Reneaulme 
de  la  Garanne,  and  unmindful  of  the  other  fact  that  it  con- 
tained no  new  principle,  and  must  have  been  entertained 
by  Tagliacozzi,  and  only  rejected  for  the  sake  of  another 
advantage  incompatible  with  it. 

In  the  so-called  French  method,  the  principles  of  which 
are  found  in  Celsus,  the  flap  has  a  broad  base,  and  is 
brought  into  place,  not  by  rotation,  but  by  traction  in  the 
direction  of  its  axis  (Figs.  99  and  110).  The  variations 
and  combinations  of  these  methods  are  now  so  numerous 
that  the  names  no  longer  have  much  descriptive  value. 

General  Principles. — The  edges  of  the  flaps  must  be 
brought  together  without  tension,  and  united  very  accu- 
rately by  means  of  fine  silk,  catgut,  or  silver  sutures. 

All  hemorrhage  must  cease  before  the  flaps  are  brought 
into  place.  Thepresence  of  a  dot  of  blood  under  a  trans- 
ferred flap  may  cause  failure. 

Flaps  must  lie  taken  from  healthy  non-eiealricial  skin, 
and  whenever  the  skin  is  thin  and  not  very  vascular  the 
subcutaneous  layer  should  be  taken  with  it  to  insure  its 
vitality. 

The  base  of  the  flap  should  occupy  the  quarter  from 
which  the  main  supply  of  blood  is  received,  and  the  direc- 


CHETLOPLASTY.  253 

tion  and  shape  of  the  flap  should  be  such  that  it  can  be 
brought  into  place  with  the  least  amount  of  twisting  of  the 
base. 

The  flap  should  be  made  considerably  larger  than  the 
space  it  is  to  fill,  and,  to  insure  accuracy,  it  is  well  to  cut 
it  according  to  a  pattern  previously  made'  of  paper  or  oil 
silk.  It  is  well  also  to  mark  the  angles  by  fine  pins 
planted  erect  in  the  skin. 

'The  raw  surface  left  by  the  dissection  of  a  Hap  may  be 
partly  covered  by  drawing  its  edges  together  with  sutures; 
the  remainder  must  be  left  to  granulate  or  may  be  cov- 
ered by  Thiersch  grafting. 

If  strict  asepsis  is  maintained  greater  tension  can  he 
made  with  the  sutures  than  would  otherwise  be  safe,  and 
the  chances  of  failure  and  of  cicatricial  contraction  are 
less. 

CHEILOPLASTY. 

A.  Lower  Lip. — Restoration  of  the  lower  lip  is  usually 
undertaken  to  make  good  the  loss  of  substance  occasioned 
by  the  removal  of  an  epithelial  tumor.  The  choice  of  a 
method  depends  upon  the  extent  of  the  disease. 

1.  V-Incision.  (Fig.  89.) — When  the  tumor  is  small, 
involving  not  more  than  one-quarter  or  one-third  of  the 
lip,  it  may  be  removed  by  a  V -incision,  and  the  sides  of  the 
gap  brought  together  with  one  or  two  points  of  inter- 
rupted or  twisted  suture.  The  mucous  membrane  on  the 
inside  of  the  lip  should  be  excised  to  the  same  extent  as 
the  skin,  although  it  is  not  usually  involved  in  the  dis- 
ease, for  otherwise  it  forms  a  disagreeable  fold  or  pucker 
in  the  lip. 

The  harelip  pins  or  sutures  must  be  deeply  placed, 
passing  close  to  the  mucous  membrane  on  the  inside,  for 
this  insures  confrontation  of  the  raw  surfaces  throughout 
their  entire  breadth  and  prevents  hemorrhage. 

'2.  Oval  Horizontal  Incision. — When  the  tumor 
covers  a  considerable  extent  of  surface,  but  does  not  pene- 
trate deeply,  it  may  be  safely  excised  by  cutting  under  it 
with  curved  scissors.     The  mucous  membrane  and  skin 


254 


PLASTIC  OPERATIONS  ON  THE  FACE. 


may  then  be  stitched  together,  <»r  the  wound  allowed  to 
heal  by  granulation. 

Fig.  89. 


Cheiloplasty.  V-incision. 


3.  Method  of  Celsus  ob  Serres.    (Figs.  90  and  91.) 
-The  y-incision  is  supplemented  by  a  horizontal  one  on 


Fig.  90. 


Fig.  91. 


Cheiloplasty.    <  elsusV  incisions.  Cheiloplasty.      Celsus' 8  flaps  iu  place, 

each  side  carried  outward  from  the  angle  of  the  mouth  for 
about  two  inches,  ami  comprising  the  whole  thickness  of 


CHEILOPLASTY.  255 

the  cheek  for  the  first  two-thirds  of  its  length,  Imt  divid- 
ing the  mucous  membrane  at  a  somewhat  higher  level  than 
the  skin.  The  lower  gingivo-labial  fold  is  divided  close 
to  the  gum  on  both  sides,  and  the  dissection  carried  down- 
ward close  to  the  periosteum,  and  backward  toward  the 
angle  of  the  jaw  until  the  edges  of  the  gap  in  the  lip  can 

Fig.  92. 


Cheiloplasty.     Dieffenbach's  method. 

be  brought  together  without  tension.  The  sides  of  the  V 
are  then  brought  together,  and  the  lip  formed  from  the 
lower  parts  of  the  horizontal  incisions  (Fig.  91).  The 
mucous  membrane  and  skin  are  stitched  together  along  the 
edge  of  the  new  lip,  and  the  remaining  portion  of  the  lower 
flap  on  each  side  (that  which  remains  external  to  the  new 
angle  of  the  mouth)  is  reunited  to  the  upper  flap.  The 
mucous  membrane  at  the  outer  end  of  the  horizontal  in- 
cision is  stitched  to  the  skin  and  covers  the  angle. 

4.  Dieffexbach  (Fig.  92)  adds  a  vertical  incision  at 
the  end  of  each  horizontal  one,  thus  marking  out  two 
quadrilateral  flaps  which  are  brought  together  in  the 
median  line.  The  gaps  left  in  the  cheek  by  the  transfer 
are  allowed  to  close  by  granulation. 

5.  Syme-Buchaxan.  (Figs.  93  and  94.) — The  method 
by  latero-inferior  flaps  is  ascribed  by  some  to  Syme,  by 
others  to  Buchanan,  of  Glasgow. 

After  the  tumor  has  been  removed  by  the  usual  V-inci- 
sion,  the  incisions  are  prolonged  downward  and  outward 
for  nearly  an  inch  and  then  curved  upward  and  outward. 


266 


PJ.ASTic  OPERATIONS  OX  THE  FACE. 


These  Maps  are  dissected  off  the  bone  and  brought  to- 
gether in  the  median  line.      The  mucous  membrane  and 


Fig.  93. 


Fig.  04. 


Svrne-Buchanan  incisions. 


Synie-Buchanan  flaps  in  place. 


skin  are  stitched  together  along  the  upper  edge,  the  gaps 
left  below  by  the  shifting  of  the  flaps  drawn  together  as 
much  as  possible  and  the  remainder  left  to  heel  by  granu- 
lation. 

Raxke  and  Tr£lat  (Figs.  95  and  96)  make  the  flap 
on  one  side  longer  and  lift  it  over  the  other  to  form  the 


Fig.  95. 


Fig.  9ti. 


Kanke  Tn'hit  Method. 


new  lip,  the  shorter  flap  being  used  as  a  support    for  the 
former, 


'  tiElLOPLASTY. 


Wi 


6.  Buck's  Method.  (Figs.  97  and  98.) — Buck  pre- 
ferred t<>  make  two  operations.  He  first  removed  the 
tumor  by  the  V-incision,  brought  the  sides  of  the  gap  to- 
gether and  allowed  them  to  unite.  After  the  union  had 
become  complete  he  restored  the  angle  of  the  month  and 
lengthened  the  lower  lip  with  material  taken  from  the 
upper  one  by  the  following  method.1 

In  Fig.  97,  11  B  represent  two  pins  inserted  a  ringer's 
breadth  below  the  under  lip  border,  one  on  either  side  of 
the  ehin,  a  little  to  the  outside  of  the  angle  of  the  mouth, 
and  equidistant   from  the  median  line  ;  I)  I>  are  also  two 

Fig.  (.'7. 


Restoration  of  lower  lip.    Back's  Incisions. 

pins  inserted,  one  on  either  side,  into  the  upper  lip  at  the 
margin  of  the  vermilion  border,  equidistant  from  the  me- 
dian line,  and  at  such  distance  apart  as  to  include  between 
them  sufficient  length  of  lip  border  for  a  new  upper  lip. 
The  steps  of  the  operation  are  then  the  following  :  With 
the  forefinger  of  the  left  hand  placed  on  the  inside  of  the 
mouth,  the  left  cheek  is  to  be  kept  moderately  on  the 
stretch  while  it  is  transfixed  with  a  sharp  knife  at  the 
point  B.  An  incision  is  then  carried  through  the  entire 
thickness  of  the  cheek,  upward  and  a  little  outward,  a  dis- 
tance of  one  inch  and  a-half  to  a  point,  E,  near  the  mid- 
dle of  the  cheek.  The  corresponding  side  of  the  upper 
lip  should  next  be  transfixed  at  the  point  IK  and  the  in- 
cision carried  through  the  lip  and  cheek  outward  and  a 
little  upward  to  join  the  first  incision  at  E. 

1  Reparative  Surgery,  1876,  \>.  '22  et  seq. 


258 


PLASTIC  OPERATIONS  <>.x  THE  FACE. 


The  next  step  is  to  transfer  the  triangular  patch,  thus 
marked  out,  from  the  cheek  to  the  side  of  the  chin.  For 
this  purpose  an  incision  should  be  made  on  the  side  of  the 
chin  from  B  vertically  downward  to  the  edge  of  the  jaw 
and  to  the  depth  of  the  periosteum.  The  edges  of  this 
incision,  retracting  wide  apart,  afford  a  V-shaped  space  for 
the    lodgment   of  the    triangular   patch,    which    is    now 


Fig.  98. 


Restoration  (if  the  lower  lii 


in  place. 


brought  around  edgewise,  and  adjusted  by  sutures  in  its 
new  position  (see  Fig.  98).  The  gap  left  in  the  cheek 
is  closed  by  bringing  its  edges  together  and  securing  them 
in  contact  by  sutures.  By  this  adjustment  a  new  and 
naturally  shaped  angle  is  formed  for  the  mouth  at  the 
point  1).  The  incisions  should  be  made  with  the  utmost 
precision,  and  special  care  should  be  taken  that  the  lining 
mucous  membrane  is  divided  exactly  to  the  same  extent 
as  the  skin. 

The  sam?  procedure  may  be  applied  to  the  other  side 
of  the  mouth,  and  executed  at  the  same  operation. 

7.  Square  Lateral  Flaps.  (Malgaigne.)  (Fig.  99.) 
— The  tumor  is  circumscribed  by  two  vertical  incisions 
carried  downward  from  the  edge  of  the  lip,  and  a  third 
horizontal  one  uniting  the  lower  ends  of  the  first  two. 
To  fill  the  square  gap  thus  created,  two  horizontal  inci- 
-ion-  are  made  on  each  side — one  from  the  angle  of  the 
mouth,  the  other  from  the  lower  corner  of  the  gap.  The 
flaps  circumscribed  by  these  incisions  are  brought  forward 


CHEILOPLASTY 


25A 


and  united  in  the  median  line  and  the  mucous  membrane 
stitched  to  the  skin  along  the  edge  of  the  lip  and  at   the 


Fig.  99. 


Cheiloplasty.    (Malgaigne.  ) 


commissures.     (See  also  3.    Method  of  Celms,  p.  254,  and 
Stomatoplasty,  v.  inf.) 

8.   Square  Vertical  Flaps.     (Fig-.  100.) — Sedillot 
made  the  flap  at  right  angles  to  the  line  of  the  mouth. 


Fir;.  100. 


Cheiloplasty.    (Sex>illot.  ) 


The  incisions  are  shown  in  Fig.  100.  Eaeh  flap  is 
swung  around  to  meet  the  other  in  the  median  line,  its 
inner  vertical  border  becoming-  the  edge  of  the  lip. 

In  any  of  these  operations  in  which  a  large  portion  of 
the  lip  is  made  by  bringing  in  a  flap  from  the  cheek,  the 


260  PLASTIC  OPEMATIOM  <>.\   THE  FACE. 

raw  surface  of  the  flap  adjoining  the  angle  of  the  mouth 
may  be  covered  in  by  a  second  flap  turned  down  (or  up) 
from  the  other  side  of  the  angle  SO  as  to  create  a  new 
vermilion  surface  and  border.  The  effect  is  much  the 
same  as  in  Buck's  operation.  Fig.  its. 

B.  Angle  of  the  Mouth  (Stomatoplasty). — An  attempt 
to  restore  a  large  portion  of  either  lip  by  means  of  ma- 
terial taken  from  the  other,  or  to  close  a  gap  by  simple 
approximation,  not  infrequently  leaves  the  mouth  small, 
rounded  and  pouting,  with  obliteration  of  one  or  both 
angles.  This  defeet  can  be  overcome  by  the  operation 
described  (p.  257)  as  Buck's  method  of  restoration  of  the 
lower  lip,  or  by  extending  the  mouth  laterally  by  a  hori- 
zontal incision  involving  both  skin  and  mucous  mem- 
brane  and  then  preventing  reunion  by  stitching  the  skin 
and  mucous  membrane  together  on  both  sides  and  at  the 
angle  of  the  incision.  Sedillot  considers  it  indispensable 
to  excise  a  portion  of  the  skin  so  as  to  have  a  compara- 
tive excess  of  mucous  membrane,  which  when  stitched  to 
the  skin  will  roll  outward  and  form  a  vermilion  border. 
This  simple  method  was  modified  by  Buck  as  follows  : 

Buck's  Operation1  for  Enlargement  of  the 
Mouth  and  Restoration  of  its  Angle.  (Fig.  101.) 
— An  incision  is  made  with  great  exactness  along  the  line 
of  the  vermilion  border  circumscribing  the  circular  half 
of  the  mouth  and  extending  to  an  equal  distance  on  the 
upper  and  lower  lips  (a  to  b).  This  incision  should  only 
divide  the  skin,  without  involving  the  mucous  membrane. 
A  sharp-pointed,  double-edged  knife  should  then  be  in- 
serted at  the  middle  of  this  curved  incision  and  directed 
flatwise  toward  the  cheek,  between  the  skin  and  mucous 
membrane,  so  as  to  separate  them  from  each  other  as  far 
as  the  new  angle  of  the  mouth  requires  to  be  extended. 
The  skin  alone  is  next  divided  from  the  commissure  of 
the  mouth  outward  toward  the  cheek.  The  underlying 
mucoilS  membrane  1S  then  divided  in  the  same  line,  but 
not  bo  far  outward.  The  angles  at  the  outer  ends  of  the 
two  incisions  are  then  accurately  united  by  a  single 
Reparative  Surgery,  p.  28  el  seq. 


CHEILOPLASTY 


261 


thread  suture.      The  fresh-cut  edges  of  skin  and  mucous 
membrane  above  and  below,  that  are  to  form  the  new  lip 


Fig.  K"l. 


bening  of  the  mouth.    (Buck.) 

borders,  are  shaped  by  paring  first  the  skin  and  then  the 
mucous  membrane  in  such  a  manner  that  the  latter  shall 


Fig.  102. 


Fig.  103. 


Cheiloplasty  of  upper  lip.    (Sepillot.) 


Sfidillot     Flaps  in  place. 


overlap  the  former,  after  they  have  been  secured  together 
by  tine  thread  sutures  inserted  at  short  intervals. 


262 


PLASTIC  OPERATIONS   ON  THE  FACE. 


C.  Upper  Lip. — The  V-hicision  and  the  oval  horizontal 
incision  (p.  253)  may  bo  used  when  the  loss  of  tissue  will 
be  small.  Also  the  square  lateral  flaps  (p.  258)  when  the 
gap  to  bo  filled  is  in  the  center  of  the  lip  and  rather  large. 

1.  Vertical  Flaps.  (Figs.  102  and  103.) — These  may 
be  made  with  the  base  directed  upward  (Sedillot)  or  down- 
ward (Chauvel).  Chauvel  claims  that  the  latter  method 
is  to  be  preferred  because  the  retraction  of  the  cicatrix  in 
the  former  tends  to  draw  the  new  lip  upward  and  expose 
the  teeth. 

The  flaps  comprise  the  entire  thickness  of  the  cheek, 
are  turned  inward  at  right  angles  to  their  former  position 
and  united  in  the  median  line.  The  gaps  left  in  the  cheek 
by  their  removal  are  brought  together  with  sutures  or  left 
to  granulate. 

2.  Infero-lateral  Flap.  (Buck.)  (Fig.  104.) — For 
loss  of  the  right  half  of  the  upper  lip  Buck  employed  the 

Fig.  101. 


Repair  of  upper  lip  by  Infero-lateral  Map.    (Buck.) 


following  method,  enlarging  the  month  afterward  and  re- 
establishing the  angle  by  the  method  described  above 
(p.  260). 


HARELir.  263 

The  extremity  of  the  under  lip,  where  it  joined  the  right 
cheek,  was  divided  through  its  entire  thickness  at  right 
angles  to  its  border,  and  the  division  carried  to  the  extent 
of  one  inch  from  the  border  (a  to  b,  Fig.  104).  A  second 
incision  was  made  from  the  terminus  of  the  first  parallel 
to  the  lip  border  for  a  distance  of  one  inch  and  a-half 
toward  the  chin,  b  to  c.  The  quadrilateral  flap  thus 
formed  from  the  under  lip  was  folded  edgewise  upon  itself, 
and  made  to  meet  the  remaining  half  of  the  upper  lip,  and 
be  adjusted  to  it  by  its  free  extremity.  In  order,  how- 
ever, to  made  this  fold,  the  under  lip  had  first  to  be 
divided  obliquely  half  across  its  base,  e  to  <J. 

The  left  half  of  the  upper  lip  was  prepared  for  the  new 
adjustment  by  dividing  the  buccal  mucous  membrane  close 
to  the  jaw  and  detaching  the  parts  above  toward  the  orbit 
from  the  underlying  periosteum,  and  secondly  by  paring  a 
strip  of  vermilion  border  from  the  extremity  of  the  half- 
lip  of  sufficient  length  to  permit  the  end  of  the  half-lip  to 
be  matched  to  the  free  extremity  of  the  under-lip  flap. 
The  parts  concerned  having  been  thus  prepared,  the 
under-lip  flap  was  doubled  edgewise  upon  itself,  and  its 
free  extremity  adjusted  to  the  half  of  the  upper  lip,  and 
the  two  secured  to  each  other  in  a  vertical  line  below  the 
columns  nasi  by  sutures.  The  space  between  the  newly 
adjusted  half  of  the  mouth  and  the  neighboring  cheek  was 
closed  by  approximating  the  opposite  parts  and  securing 
them  to  each  other  by  sutures  after  their  edges  had  been 
carefully  matched.  (Fig.  101  shows  the  result  of  this 
operation.) 

HARELIP. 

If  the  patient  is  a  young  child  its  arms  should  be 
securely  bound  to  its  sides  with  a  towel,  and  its  head 
firmly  held  by  an  assistant.  After  anaesthesia  has  been 
obtained  it  can  be  easily  kept  up  by  applying  to  the  nos- 
trils from  time  to  time  sponges  saturated  with  ether. 

Single  Harelip,  Simple. — The  simplest  method  of  oper- 
ating is  to  pare  the  sides  of  the  cleft  and  bring  the  raw 
surfaces  together  by  a  few  sutures.     The  objection  to  the 


264 


PLASTIC   OPERATIONS  OS  THE  FACE. 


method  is  that  the  retraction  of  the  soar  produces  a  more 
or  less  considerable  depression  in  the  free  border  of  the 
lip.  It  has  therefore  been  generally  abandoned  for  one  of 
the  following  : 

1.  Double  Flaps.  (Fig.  105.) — In  order  to  hold  the 
parts  upon  the  stretch  and  insure  precision  in  making  the 
cuts,  a  stout  ligature  should  be  passed  through  the  lip  at 
each  angle  of  the  cleft,  or  each  angle  should  be  seized 
with  a  tenaculum.  The  lip  being  drawn  forward  and 
downward  by  means  of  the  ligature  or  tenaculum,  the 
mucous  membrane  is  divided  close  to  the  gum  and  the 
dissection  carried  upward  and  backward  as  far  as  may  be 
necessary  to  allow  the  sides  of  the  cleft  to  be  brought  to- 
gether without  tension. 

Pig.  105. 


Simple  single  harelip,  double  Baps.    A.    incision: 
Ligature  for  holding  lip  tense.     i>.    incision   to 
Thread  (>:isseil  through  the  ends  of  the  Baps. 


/>'.   Flaps  turned  down.    C. 
horten  and  adjust   (laps.     ]•:. 


Then  making  one  side  of  the  cleft  tense,  by  drawing 
upon  its  ligature,  the  lip  is  transfixed  near  the  angle  and 
ill'  incision  carried  upward  along  the  border  of  the  cleft 
to  it>  top,  or,  if  necessary,  into  the  nostril,  thus  cutting 
•  Hit  ;i  narrow  flap  which  remains  attached  at  its  lower  ex- 
tremity to  the  lip  (Fig.  105,  -1).  A  similar  Hap  is  then 
made  upon  the  other  side,  the  two  arc  turned  down,  so 
that  their  raw  surfaces  face  each  other,  and  a  thread 
passed  through  their  free  ends  (Fig.   L05,   I''). 

TIk  freshened  edges  of  the  cleft  are  then  confronted,  a 
harelip  pin  placed  near  the  vermilion  border  and  another 


UMii-iur. 


265 


near  the  nostril,  and  two  or  three  fine  silk  or  silver  sutures 
inserted  between  them.  The  ends  of  the  dependent  Haj>s 
axe  then  cutoff  obliquely,  enough  being  left  to  form  a  dis- 
tinct projection  on  the  lip  after  they  have  been  united 
with  fine  sutures.  By  this  means  the  formation  of  a 
notch  by  the  retraction  of  the  cicatrix  is  avoided. 

'2.  When  the  cleft  Mas  shallow,  Xelaton  left  the  flaps 
attached  to  each  other  at  the  apex,  turned  them  down,  and 
brought  the  raw  surfaces  together  as  above  described 
(Fig.  106). 

3.  Single  Flap.  (Fig.  107.) — A  flap  is  made  upon 
one  side  only,  usually  the  shorter  portion  of  the  lip.     The 

Fig.  106. 


Harelip.    Nelaton's  method.     .1.  Incision.     />'.  Flap  tnrned  down. 

opposite  side  of  the  cleft,  and  a  portion  of  the  free  border 
of  the  lip  adjoining  it  are  freshened  by  the  removal  of  a 
strip  of  skin  and  mucous  membrane.      The  sides  of  the 

Fig.  107. 


Harelip.        single  flap. 


cleft  are  approximated,  and  the  flap  applied  to  the  free 
border  of  the  lip. 

4.  Giraldes's    Method.     (Fig.   108.) — This    is  ap- 
plicable only  when  the  cleft  extends  into  the  nostril.     The 


266 


PLASTIC  OPERATIONS  ON  THE  FACE. 


flap  on  the  short  side  is  made,  as  before  described,  with 
it-  base  below;  that  on  the  long  side  is  reversed,  being 
left  attached  at  its  upper  end.  A  third,  horizontal  incision 
is  carried   outward   from    the   edge  of  the  nostril,  at  the 


Fig.  L08. 


Harelip.       Giraldes's  method. 

point  of  the  first  flap,  to  make  that  portion  of  the  lip  more 
movable.  The  second  flap  is  then  turned  upward  across 
the  nostril,  the  first  brought  down  to  take  its  place,  and 
the  two  raw  surfaces  thus  brought  into  contact  united  by 
sutures.  The  long  side  of  the  lip  may  also  be  mobilized, 
if  desirable,  by  a  horizontal  incision  running  from  the  gap 
close  below  the  columna  and  the  corresponding  nostril. 

Double  Harelip,  Simple.      (Fig.  109.) — Flaps  are  made 
upon   the  lateral    portions,  .1  and    B,  as  before  described 

Fig.  J  on. 


Double  harelip 


(p.  265,  3),  and    the  sides    of  the    central    portion,   (  \  are 

pared.     The  flaps  are  then  brought  together,  as  shown  in 


HARELIP.  267 

the  figure,  after  mobilizing  the  lip  by  tree  division  of  the 
gingivo-labial  fold  and  carrying  the  dissection  well  up- 
ward and  outward,  pins  passed  to  include  the  sides  and 
the  central  portion  at  the  base  and  apex  of  the  latter,  the 
Baps  trimmed  and  united  with  fine  sutures. 

If  the  parts  arc  too  scanty  to  permit  the  use  of  this 
method,  liberating  incisions  must  be  made  around  the  alae 
nasi,  or  flaps  obtained  from  the  cheek.  (See  Upper  Lip, 
p.  262  ct  seq.) 

Complicated  Harelip. — Harelip  may  be  complicated  by 
fissure  of  the  palate  and  alveolar  process.  When  the 
fissure  is  single  the  bone  on  the  long  side  of  the  lip  projects 
beyond  its  proper  line.  In  very  young  children,  it  may 
sometimes  be  forced  back  into  place  by  making  pressure 
upon  it  with  the  thumb,  but  it  is  easier  to  fracture  it  first 
with  Butcher's  pliers,  the  bent  blade  of  this  instrument 
being  applied  upon  the  anterior  surface  near  the  further 
nostril.  The  two  portions  of  the  alveolar  arch  soon  unite 
after  they  have  been  brought  into  contact,  especially  if  the 
opposing  surfaces  have  been  pared.  Sutures  are  not 
needed. 

When  there  is  double  fissure,  the  intermediate  portion 
of  bone  containing  the  incisor  teeth  projects  so  far  that  it 
seems  to  be  an  appendage  of  the  nose  rather  than  of  the 
mouth.  In  order  to  restore  it  to  its  place,  it  is  necessary 
to  divide  the  vomer  with  strong  scissors,  or,  better,  to  cut 
a  triangular  piece  out  of  the  septum  of  the  nose.  It  is 
not  necessary  to  fasten  the  bones  together  with  sutures. 
The  portion  of  skin  covering  the  projecting  bone  must  be 
dissected  off  and  used  to  lengthen  the  columna  nasi  or  fill 
out  the  lip. 

In  extreme  cases  it  may  be  proper  to  cut  away  the  pro- 
jection entirely  ;  but  whenever  it  can  be  saved  and  brought 
into  line,  it  renders  valuable  service  by  giving  the  upper 
jaw  its  proper  length  and  furnishing  a  space  into  which 
artificial  teeth  can  be  fitted.  The  three  or  four  teeth 
which  are  found  in  this  piece  are  always  so  defective  and 
irregularly  placed  that  they  have  to  be  drawn. 

For  uranoplasty,  etc.,  see  Operations  upon  the   Mouth. 


268  plastic  OPERATIONS  ON   THE  FACE. 

RHINOPLASTY. 

The  different  kinds  of  rhinoplastic  operations  may  be 
classified  according  to  the  nature  and  extent  of  the  loss 
which  they  are  designed  to  repair:  1st.  A  superficial  loss 
not  involving-  the  bones  or  septum.  2d.  Loss  of  the  sep- 
tum and  nasal  bones,  the  skin  remaining  entire.  3d. 
Loss  of  more  or  less  of  the  surface  and  septum. 

As  the  loss  of  tissue  is  always  the  result  of  injury  or 
disease,  it  presents  so  many  variations  in  form  and  ex- 
tent, that  it  is  difficult  in  practice  to  determine  the  exact 
boundaries  between  the  classes,  and  this  classification  is 
chosen  for  convenience  of  description,  and  not  with  the 
intention  of  limiting  the  choice  of  an  operation  in  any 
given  case  to  those  described  in  the  class  to  which  the 
lesion  might  belong.  For  the  same  reason,  a  description 
of  an  operation  as  actually  performed  will  sometimes  be 
more  serviceable  than  any  general  rules  that  might  be  laid 
down. 

A.s  may  be  readily  understood,  the  existence  or  non- 
existence of  the  septum  and  nasal  bones  affects  materially, 
not  only  the  method  of  operating,  but  also  the  result.  If 
unsupported  centrally,  the  new  member  tends  constantly 
t<.  shrink  and  flatten,  and  the  surgeon  has  the  mortifica- 
tion of  seeing  that  he  has  merely  substituted  one  de- 
formity for  another.  Oilier  tried  to  meet  this  want  by 
including  the  periosteum  in  the  flap  taken  from  the  fore- 
bead  by  tin'  Indian  method.  There  was,  however,  no 
new  formation  of  bone,  and  the  operation  in  that  respect 
w;is  a  failure.  On  another  occasion  he  took  a  strip  of 
healthy  periosteum  from  one  of  the  limbs,  and  tried  to 
graft  it  under  the  skin  of  the  forehead,  hoping  thereby  to 
procure  a  lamella  of  bone,  which  could  be  used  to  give 
solidity  to  the  new  nose.  Thinking  the  graft  had  failed, 
he  withdrew  the  strip  of  periosteum  after  a  lew  days,  and 
then  discovered  that  it  had  united  nicely  at  one  point. 
There    i-    reason,  therefore,  to  think    that    a    more    patient 

repetition  of  the  experiment  might  be  successful.     On  a 
third  occasion,  lie  included  the  periosteum  of  the  fore- 


miisoi'LAsrv 


269 


head  in  ;i  flap  transferred  by  a  modification  of  the  French 
method,  and  by   folding  it   together  longitudinally  along 

the  center   lie  got  reproduction  of  bone  where  the  two 
layers  faced  each  other. 

1.  Superficial  Defect  not  Involving  the  Bones  or  Septum. 
—  If  the  loss  of  tissue  is  confined  to  the  integument,  that 
is  if  the  cartilage  is  spared,  as  it  usually  is  in  eases  of  epi- 
thelioma, no  plastic  operation  should  he  undertaken.  The 
tumor  must  he  carefully  dissected  off  and  the  wound  grafted 
or  left  to  granulate.  The  slight  mobility  of  the  integu- 
ment of  the  region  prevents  deformity  by  cicatricial  re- 
traction and  the  wound  heals  over,  leaving  a  scar  which 
does  not  contrast  offensively  with  the  neighboring  skin. 

Ii\  on  the  other  hand,  there  is  a  gap  to  be  filled,  one 
that  is  small  and  docs  not  involve  the  free  border  of  the 
ala,  square  lateral  flaps  may  be  made  by  horizontal  inci- 
sions (Fig.  110),  and  drawn  together  after  they  have  been 
rendered  freely  movable  by  dissection  from  the  underly- 
ing parts. 

Fig.  110. 


Rhinoplasty.     Lateral  flaj 


If  the  gap  is  larger,  or  if  one  of  the  alse  is  lost,  suitable 
oblique  or  vertical  flaps  may  be  taken  from  the  nose  or 
cheek  and  transferred  by  rotation.  Three  of  the  many 
variations  of  this  method  are  shown  in  Fio-s.  Ill  and 
112.  Fig.  Ill,  .1,  represents  a  vertical  flap  taken  from 
the  cheek  beside  and  below  the  nose  and  left  adherent  at 


270 


PLASTIC  OPERATIONS  ON  THE  FACE. 


its  upper  end.  The  flap  should  be  cut  long  enough  to  al- 
low a  natural  appearance  to  be  given  to  the  five  border 
of  the  ala  by  turning  it  in  upon  itself.  The  device  will  also 
prevent  excessive  cicatricial  contraction  of  the  border  and 
consequent  narrowing  of  the  nostril. 


Fig.  HI. 


Fig.  112. 


Rhinoplasty.    A.  single  lateral  flap. 
H.   Langenbeck's  method. 


Rhinoplasty.     Denonvillier's  method. 


Denonvilliee's  Method  (Fig.  112)  sometimes  makes 
it  possible  to  secure  this  object  more  certainly  by  supply- 
ing a  border  that  is  already  cicatrized.  Supposing  the 
lower  portion  of  an  ala  to  be  lost,  a  triangular  flap,  left 
adherent  to  the  lobe  of  the  nose,  is  marked  out  by  an  in- 
cision which,  starting  from  a  point  near  the  lobe  on  the 
unaffected  side  of  the  median  line,  is  carried  directly  up- 
ward nearly  to  the  root  of  the  nose,  and  thence  obliquely 
downward  to  the  upper  outer  corner  of  the  affected  ala. 
The  flap  is  mobilized  by  careful  dissection  of  the  bone 
and  cartilage  and  transferred  downward.  The  gap  left 
by  the  transfer  heals  by  granulation  or  can  be  closed  by 
a  Thiersch  graft.  For  the  sake  of  oivinjr  more  stiffness 
to  the  border,  Denonvillier  sometimes  included  a  strip  of 
cartilage  in  it. 

Von  LANGENBECE  '  restored  an  ala  by  taking  a  tri- 
angular flap  from  the  opposite  side  of  the  nose  (Fig.  Ill, 

i-  ill-  <  birnrgie  Plastique  d'apres  lee  Preceptes  du  Prof.  B.  von 
Longenbeck,  Bruxelles,  1856,  quoted  by  Verneuil. 


UH1N0PLA8TY.  271 

/»').  The  flap  was  left  adherent  at  the  apex  of  the  trian- 
irlo,  which  lay  near  the  inner  angle  of  the  eve  of  the  al- 
fected  side,  while  its  base  occupied  the  opposite  ala.     It 

was  dissected  up  carefully  so  as  not  to  include  the  car- 
tilage, transferred  to  the  other  side  and  fastened  to  the 
freshened  edges  of  the  gap.  The  wound  left  by  the  re- 
moval of  the  Hap  healed  by  granulation  and  so  perfectly 
that  it  was  difficult  to  recognize  there  had  been  any  loss 
of  tissue  at  that  point. 

MlOHON  restored  the  ala  by  taking  a  triangular  Hap 
from  the  septum.  The  base  of  the  flap  was  placed  ante- 
riorly, parallel  to  the  ridge  of  the  nose,  and  the  apex  lay 
near  the  junction  of  the  septum  with  the  floor  of  the  nasal 
fossa.  The  flap  was  dissected  up  and  attached  to  the 
margin  of  the  loss  of  substance,  its  mucous  surface  di- 
rected outward,  its  apex  made  fast  to  the  cheek. 

The  coli'mxa,  with  or  without  the  tip  of  the  nose, 
can  be  restored  from  the  upper  lip.  Dupuytren  and 
Dieffenbach  cut  a  vertical  cutaneous  flap,  adherent  at 
its  upper  end,  immediately  below  the  columna,  turned  it 
upward,  twisting  it  upon  its  pedicle  so  that  its  cutaneous 
surface  remained  external,  and  secured  it  in  place.  As 
the  twisting  of  the  pedicle  created  considerable  deformity, 
Sedillot  and  Blandin  made  the  flap  of  the  entire  thickness 
and  length  of  the  lip,  pared  off  its  cutaneous  surface,  and 
turned  it  directly  upward  without  twisting  the  pedicle, 
the  mucous  membrane  thus  forming  the  outer  surface. 
The  gap  left  in  the  lip  was  then  closed  with  sutures.  In 
Blandin's  case  the  result  was  excellent,  and  the  mucous 
membrane  gradually  assumed  the  characteristics  of  ordi- 
nary skin  ;  but  in  Sedillot's  ease,  in  which  the  tip  of  the 
nose  had  also  to  be  restored,  the  membrane  remained  red 
and  covered  with  thick  epidermic  scales,  and  the  end  of 
the  nose  looked  much  like  a  cherry.1  In  all  his  rhino- 
plastic  operations  Liston  made  the  columna  separately  by 
this  method,  and  found  that  the  mucous  membrane  soon 
took  on  the  appearance  of  ordinary  integument. 

'Sedillot  :  Medecine  Op&atoire,  2d  ed.,  Vol.  II.,  p.  233. 


272  PLASTIC  OPERATIONS  ON  THE  FACE. 

2.  Loss  of  the  Septum  and  Nasal  Bones,  the  Skin 
Remaining  Entire. —  Baron  Larrey,  about  1820,  operated 
upon  a  soldier  the  bridge  of  whose  nose  had  been  shat- 
tered and  depressed  by  the  explosion  of  a  gun.  He  re- 
moved the  deformity  by  dissecting  up  the  adherent  por- 
tions of  skin  and  replacing  them  in  their  original  position. 
The  details  of  the  operation  are  lacking. 

Dieffenbach  published  in  1829  the  description  of  an  op- 
eration by  which  he  overcame  the  great  deformity  result- 
ing from  the  loss  of  the  septum  and  bones  of  the  nose  by 
scrofulous  disease.      As  the  case  is  a  classical  one,  quoted, 

Pig.  11.°.. 


Dieffenbach's  operation.     />'.  Tli 


and  often  very  incorrectly,  in  the  text-hooks,  and  is  an 
indication  of  whal  may  sometimes  he  accomplished  in  ex- 
treme eases,  the  following  description  of  it  is  given  :' 

The  patient  was  a  girl  twelve  years  of  age.  She  had 
lost    th*'   OSSa    nasi,  nasal    process  of  the   ethmoid,  vomer, 

1  A-  the  original  work  could  no!  be  obtained,  this  description  is  made 
up  from  an  English  translation  of  the  book,  published  in  1833,  a  French 
translation  of  the  case,  in  the  Gazette  M£dicale,  Vol.  I.,  p.  65,  1830,  and 
:i  brief,  description  with  plates,  in  a  collection  of  Dieffenbach's  Plastic 
Operations,  published  by  two  of  his  pupils  in  1846. 


RHINOPLASTY.  273 

and  cartilages,  and  instead  of  a  prominent  nose  there  was 
a  deep  pit  with  a  ridge  at  the  bottom.  The  plan  of  oper- 
ation was  to  divide  the  remains  of  the  <>ld  sunken  mem- 
ber into  portions,  raise  them  up,  and  secure  them  in  the 
proper  position.  Dieffenbach  passed  a  narrow-bladed 
knife  first  into  one  nostril  and  then  into  the  other,  and  cut 
out,  making  two  incisions,  one  on  each  side  of  the  sunken 
ridge.  (Fig.  113,  C.)  The  strip  of  skin  between  these  in- 
cisions was  three  times  as  broad  at  its  lower  end,  where 
it  was  connected  with  the  upper  lip  by  the  shortened 
columna,  as  at  its  upper  part  where  it  joined  the  forehead. 
The  cheeks  were  next  cut  through  down  to  the  bones  on 
each  side  by  inserting  the  knife  a  few  lines  below  the 
upper  end  of  the  first  incision  and  carrying  it  obliquely 
downward,  parallel  and  a  little  external  to  the  side  of  the 
nose,  and  then  around  into  the  nostril,  thus  separating  the 
lateral  attachments  of  the  ahe  nasi.  The  columna,  being 
too  short,  was  then  elongated  by  two  slight  incisions  in  the 
upper  lip,  and  the  cheeks  rendered  more  movable  bv  di- 
viding their  attachments  to  the  bone  through  the  lateral 
incisions.  The  flaps  were  then  raised,  the  sides  of  the'in- 
cisions  pared  obliquely  in  a  manner  to  which  Dieffenbach 
attaches  an  importance  that  seems  undeserved,  reunited, 
and  fixed  with  harelip  pins  and  sutures,  and  the  whole  re- 
tained in  place  by  drawing  the  cheeks  toward  the  median 
line  and  fastening  them  there  with  two  long  pins  passed 
under  the  nose  and  through  the  detached  edges  of  the 
cheeks.  This  compression  was  aided  by  two  splints  of 
leather  through  which  the  pins  passed.  A  quill  covered 
with  oiled  lint  was  introduced  into  each  nostril. 

Osteoplastic  Method. — Oilier  successfully  treated  a  some- 
what similar  ease  by  making  a  triangular  Hap,  its  base 
constituted  by  the  lower  portion  of  the  nose  and  the  ad- 
joining cheeks,  its  apex  situated  one  and  a-half  inches 
above  the  eyebrows.  The  frontal  portion  of  the  flap  in- 
cluded the  underlying  periosteum.  The  left  nasal  bone 
and  vomer  having  been  destroyed  by  the  disease,  central 
support  could  be  obtained  for  the  new  nose  only  by  aid  of 
the  right  nasal  bone,  which  was  accordingly  loosened  with 
is 


-7  1 


PLASTIC  OPERATIONS  ON   Till':  FACE. 


a  chisel  and  forced  downward.  The  flap  was  then  trans- 
ferred downward,  pinched  in  laterally  to  increase  its 
height  at  the  bridge,  and  supported  there  by  drawing  the 
cheeks,  previously  loosened  from  their  underlying  attach- 
ments, toward  the  nose  and  fastening  them  there  with  long 
pins.1 

Double  Layer,  or  Superficial  Flaps.  (Fig.  114.) — Ver- 
neiiil  '  employed  successfully  a  method  suggested  to  him 
by  Oilier,  in  which  permanent  elevation  of  the  bridge  of 
the  cose  was  secured  by  superposing  two  Haps  and  thereby 
doubling    the  thickness.     The  patient  had  discharged  a 

Fig.   114. 


VW 


>— 


Rhinoplasty,  sunken  □ 


Double  layer,  or  superposed  Baps.     (Verneuil.) 


pistol  into  his  i ith,  causing  the  destruction  of  a  portion 

of  the  hard  palate  and  septum,  the  nasal  bones,  part  of 
the  nasal  processes  of  the  superior  maxillary,  the  spine  of 
the  frontal,  and  the  anterior  wall  of  the  frontal  sinuses. 
The   alffi   and    lobe    were    uninjured    but     much    flattened  ; 

above  them  was  a  broad  deep  groove  extending  to  the 
middle  third  of  the  forehead.     The  two  principal  indica- 

1  For  farther  detail*  "f  tin-  operation  the  reader  is  referred  to  the 

original  account  in  the  Bulletin  de  la  Soci&e*  de  Chirurgie,  L862,  \>.  62; 

..i  !.,  ii    reproduction  in  Verneuil's  ( hirurgie  R<Sparatrice,  p.  128,  and  in 

sette  Hebdomadaire,  1862,  p.  98,  and  also  to  a  similar  operation 

described  more  fully  on  |>.  279  of  tin*  manual. 

-  (  hirurgie  Reparatnce,  p.  128,  and  Bull,  de  la  Soc.  de  Chirurgie; 
1862,  p.  7". 


RHINOPLASTY.  275 

tit  his  were  to  bring  the  lateral  portions  nearer  the  median 
line  and  to  reconstitute  the  bridge  of  the  nose.  The  latter 
could  be  permanently  accomplished  only  by  filling  in  the 
great  cavity  which  would  be  left  by  raising  the  sunken 
parts. 

Verneuil  made  an  incision  along  the  median  line  of  the 
depression  and  a  transverse  one  at  each  end  of  the  first, 
and  dissected  up  the  two  lateral  flaps  thus  marked  out. 
Me  then  raised  an  oblong  flap  from  the  middle  of  the  fore- 
head, its  base  remaining  adherent  between  the  eyebrows, 
and  turned  it  directly  downward  so  that  its  raw  surface  was 
directed  outward,  its  tegumentary  surface  toward  the  nasal 
fossre.  The  two  lateral  flaps  were  then  placed  upon  it 
and  united  in  the  median  line.  The  raw  surfaces  united 
with  each  other,  and  the  result  was  a  nose  elevated  one- 
third  of  an  inch  above  the  adjoining  surface. 

Subcutaneous  Method. — Prof.  Pancoast '  operated  upon 
a  similar  case  in  the  winter  of  1842—4.*)  by  subcutaneous 
division  of  the  adhesions.  The  ossa  nasi  and  septum  had 
been  entirely  destroyed  by  disease,  and  the  nose  was 
sunken  far  below  the  level  of  the  face.  "A  narrow  long- 
bladed  tenotomy  knife  was  introduced  on  either  side  by 
puncture  through  the  skin  over  the  edge  of  the  nasal  proc- 
ess of  the  upper  maxillary  bone.  The  knife  was  pushed 
up  under  the  skin  to  the  top  of  the  nasal  cavity,  and  then 
brought  down,  shaving  the  inside  of  the  bony  wall,  so  as 
to  detach  the  adherent  and  inverted  nose  upon  either  side. 
The  point  of  the  nose  could  now  be  drawn  out.  *  *  *  The 
nose  still  remained  adherent  to  the  top  of  the  nasal  chasm. 
The  knife  was  a  third  time  introduced  under  the  skin  in  a 
direction  corresponding  nearly  with  the  long  diameter  of 
the  orbits  of  the  eyes  and  the  adhesions  separated  from 
the  nasal  spine  and  internal  angular  processes  of  the  os 
froutis."  The  soft  parts  on  the  cheek  were  loosened  bv 
sweeping  the  knife  outward  along  the  surface  of  the  bone 
so  far  as  to  divide  the  infra-orbital  nerve  and  artery  on 
each  side,  drawn  toward  the  median  line,  and  held  together 
with  quilled  sutures  passed  through  the  cavity  of  the  nose. 
1  Operative  Surgery,  l'hila.,  1852,  p.  858. 


276  PLASTIC  OPERATIONS  OJV   THE  FACE. 

In  two  weeks  the  root  of  the  new  nose  had  sunk  to  the 
level  of  the  face,  but  the  patient  was  well  satisfied,  and 
refused  any  further  operation,  beyond  the  removal  of  an 
elliptical  piece  of  skin  to  raise  this  portion  again.  The 
ultimate  result  is  not  known. 

Dubrueil1  quotes  a  similar  operation  by  Malgaigne,  but 
without  giving  the  date.  As  it  is  not  mentioned  in  the 
hitter's  Mideoine  Opiratoire,  edition  of  1837,  it  is  probable 
that  Prof.  Paneoast's  operation  antedates  it. 

About  189o  I  successfully  met  the  indication  in  a  case 
of  depression  of  the  bridge  due  to  fracture  of  the  nasal 
bones  by  introducing  a  piece  of  guttapercha  through  a 
small  incision  on  the  side  of  the  nose.  See  Fractures  and 
Dislocations,  1898,  p.  156. 

3.  Loss  of  more  or  less  of  the  Surface  and  the  Septum. 

A.  Indian  Method. — This  method  was  introduced  into 
Europe  in  1814,  by  Carpue,  an  English  surgeon,  and  the 
stimulus  given  by  it  to  this  class  of  operations  was  so  great 
during  the  succeeding  twenty-five  or  thirty  years  that  this 
period  has  been  called  that  of  the  renaissance  of  rhinoplas- 
ty surgery.  The  ultimate  results,  however,  were  not 
very  favorable,  and  the  method  has  fallen  into  compara- 
tive neglect.  It  was  found  that  the  noses,  although  suf- 
ficiently full,  or  even  excessive  at  the  time  of  opera- 
tion, underwent  gradual  atrophy,  and,  when  central  sup- 
port was  lacking,  sank  to  the  level  of  the  checks.  The 
nostrils,  too,  closed  sometimes  to  such  an  extent  that  they 
would  hardly  admit  a  probe;  and,  finally,  the  whole  flap 
had  a  tendency  to  slide  downward,  and  collect  in  a  lump 
at  the  end  of  the  nose  alter  division  or  excision  of  the 
pedidc.  The  scar  left  upon  the  forehead  was  a  serious 
disfigurement,  and  the  attempt  to  diminish  it  by  drawing 
the  sides  of  the  gap  together  gave  rise  to  complications 
which  endangered  the  patient's  life.      The  operation  itself 

was  not  without  danger.     Dieffenbach  lost  two  out  of  six 
patients  upon  whom  he  operated  in  Paris. 

The  operation  was  originally  performed  as  follows  (Fig. 
I  15):  A  Hap,  the  size  and  shape  of  which  were  determined 
1  Mldecine  '  >p£ratoire,  p.  151. 


RHINOPLASTY.  277 

I  >v  a  pattern  previously  made  of  paper  or  card,  was  marked 
out  upon  the  forehead  immediately  above  the  nose,  ('arc 
was  taken  to  make  it  at  least  a  quarter  of  an  inch  broader 
and  half  an  inch  longer  than  the  space  it  was  to  fill.  Its 
base  was  situated  between  the  eyebrows  and  was  half  an 
inch  broad.     At  the  upper  end  of  the  flap  was  a  project- 

Fig.  115. 


Rhinoplasty.    Indian  method  unmodified. 


ing  tab  intended  to  form  the  columna.  The  flap,  includ- 
ing all  the  tissues  down  to,  but  not  through,  the  peri- 
osteum, was  then  dissected  up,  brought  down  by  twisting 
the  pedicle,  placed  in  its  new  position  with  its  raw  surface 
inward  and  attached  by  sutures  to  the  freshened  edge-  of 
the  gap  it  was  to  fill.  Prominence  was  given  to  the  ridge 
by  stuffing  the  nostrils  with  plugs  of  oiled  lint,  or  draw- 
ing the  cheeks  toward  the  median  line  by  means  of  long 
pins  passed  transversely  through  the  edges  and  under  the 
nose.  The  gap  in  the  forehead  was  left  to  heal  by  granu- 
lation. After  the  flap  had  united,  the  pedicle  was  divided 
and  returned  to  its  original  position. 

Modifications.1 — Larrey  (1820)  pointed  out  the  desira- 

'The  dates  of  these  modifications  ami  the  award  of  credit  for  their 
suggestion  are  mainly  taken  from  Venn-nil's  Chirurgie  Reparatrice,  to 
which  the  reader  is  referred  f<>r  farther  details  and  documentary  proof. 


278  Pl.ASTlc  OPERATIONS  o.V   Till]  FACE. 

bility  of  saving  even  the  smallest  fragments  of  the  original 
nose,  especially  If  they  belonged  to  the  free  border  of  the 
ala.  Professor  Bouisson  '  formulated  this  principle  and 
extended  it  to  the  other  methods,  as  follows:  1st.  Save 
as  much  as  possible  of  the  septum.  2d.  Give  lateral  sup- 
port to  the  flaps  by  means  of  the  healthy  portion  of  the 
cartilage  of  the  alae.  3d.  Insure  the  regularity  of  the 
outline  of  the  nostril  by  giving  the  lower  border  of  the 
flap  cartilaginous  support.  Dupuytren  and  Pieffenbach 
opposed  the  retraction  and  closure  of  the  nostrils  by  fold- 
ing back  upon  itself  that  portion  of  the  edge  of  the  flap 
which  was  to  form  the  free  border. 

The  torsion  of  the  pedicle  involves  more  or  less  danger 
of  gangrene  by  obstructing  the  return  of  the  venous  blood. 
Lisfranc  (1826)  was  the  first  to  attempt  to  diminish  this 
defect.  By  lengthening  the  incision  on  one  side,  the  base 
or  attachment  of  the  pedicle  was  made  oblique  instead  of 
transverse  and  the  torsion  correspondingly  diminished  at 
that  point.  Of  course,  the  total  amount  of  torsion  re- 
mained the  same,  but,  by  being  spread  along  the  pedicle, 
it  was  made  more  spiral  and  less  abrupt.  Von  Langen- 
beck  (before  1856)  went  a  step  further  and  put  the  base 
upon  the  side  of  the  nose  close  to  the  eye,  the  upper  inci- 
sion ending  at  the  eyebrow,  the  lower  just  below  the 
tendo  oculi.      Labbat   did  about  the  same  thing  in  1827. 

Auvert,  a  Russian  surgeon  (date  unknown,  but  long 
before  1850),  made  the  flap  oblique  instead  of  vertical, 
still  keeping  the  base  between  the  eyebrows.  Alquie,  of 
Montpellier  (  1850),  proposed  to  make  the  Hap  horizontal, 
the  lower  incision  being  hidden  by  the  eyebrow  ;  and 
Landreau  even  curved  it  somewhat  upward  at  the  end,  so 
that  the  base  of  the  pedicle  was  hardly  twisted  at  all  in 
bringing  down  the  flap.  Ward  i  185  1)  made  a  flap  which 
was  directed  obliquely  upward,  ami  Follin  (1856)  made  a 
transverse  one;  in  each  ease  the  base  of  the  pedicle  was 

upon    or   near   the    median    line   of   the    forehead,   a    little 
above    the   eyebrows.      Both    cases  did    well.      The  objec- 
tion to  a  transverse  flap  is  that  the  retraction  of  the  cica- 
'  Ethinoplastie  lat^rale. 


RHINOPLASTY  279 

trix  upon  the  forehead  draws  the  corresponding  eyebrow 
upward.  The  advantages  arc  that  the  torsion  is  less,  and 
the  scar  somewhat  disguised  by  the  natural  lines. 

Various  means  have  been  employed  to  prevent  the 
descent  of  the  Hap.  Dieffenbach  made  a  longitudinal 
incision  on  the  side  of  the  nose,  and  engaged  the  pedicle 
in  it,  paring  off  its  prominences  afterward.  Blandin  ex- 
cised the  portion  of  skin  intermediate  between  the  base  of 
the  pedicle  and  the  loss  of  substance,  and  thus  obtained  a 
raw  surface  to  which  the  whole  length  of  the  pedicle  was 
then  united.  Instead  of  excising  this  intermediate  piece 
of  skin.  Buck  left  it  attached  by  its  upper  end,  and  used 
it  to  cover  part  of  the  gap  left  upon  the  forehead.  Vel- 
peau  divided  the  pedicle  close  to  its  base,  trimmed  it  to  a 
point,  and  engaged  it  in  a  vertical  incision  made  in  the 
underlying  skin. 

B.  Oi-lier's  Osteoplastic  Method.1  (Fig.  116.) — 
A  lupus  had  destroyed  the  al;e,  columna,  lobe,  cartilages, 
and  part  of  the  septum.  The  nasal  bones  were  uninjured, 
but  had  suffered  an  arrest  of  development,  and  were 
bounded  inferiorly  by  a  strip  of  cartilage.  The  nose  was 
not  more  than  an  inch  long.  The  skin  of  the  cheeks  and 
lips  had  also  been  involved  by  the  lupus,  and,  therefore, 
could  not  be  used  for  the  restoration. 

Starting  from  a  point  in  the  median  line  of  the  forehead 
two  inches  above  the  eyebrows,  Oilier  made  two  incisions 
diverging  downward,  each  of  which  ended  a  quarter  of  an 
inch  to  the  outer  side  of  the  lower  border  of  the  nasal 
orifice. 

In  dissecting  up  the  long  triangular  flap  thus  marked 
out,  he  included  the  periosteum  from  above  downward  as 
far  as  to  the  upper  end  of  the  nasal  bones  ;  he  then  con- 
tinued the  dissection  along  the  right  nasal  bone,  leaving 
the  periosteum  adherent  to  it,  and  on  reaching  the  lower 
end  of  the  bone  he  separated  from  it  the  cartilaginous  strip 
above  mentioned,  leaving  it  adherent  to  the  flap. 

On  the  left  side  he  divided,  with  a  chisel,  the  bony  con- 
nections of  the  left  nasal  bone,  leaving  the  bone  attached 
1  Traits  de  la  Regeneration  des  Os,  Vol.  II.,  p,  469. 


280 


PL  [STIC  OPERATIONS   ON   THE  FACE. 


to  the  Hap  by  its  anterior  surface;  this  was  accomplished 
by  introducing  the  chisel,  first  between  the  two  nasal 
bones,  then  between  the  left  nasal  bone  and  the  frontal, 
and  finally  between  the  left  nasal  bone  and  the  nasal  proc- 
ess of  the  superior  maxillary.  Drawing  the  flap  down- 
ward, he  then  divided  the  cartilaginous  septum  from  before 


Fig,  IKi 


thinoplasty.    Ollier's  osteoplastic  method, 


backward  and  downward  with  scissors,  so  as  to  have  an 
anterc-posterior  Hap  of  cartilage  attached  by  its  base  to 
the  cutaneous  one,  and  able  to  furnish  central  support  for 
the  new  nose  by  resting  its  free  border  upon  the  floor  of 
the  nasal  fossa,  or  rather  upon  the  remains  of  the  lower 
portion  of  the  original  septum. 

lie  next  drew  the  whole  Hap  downward  until  the  upper 
border  of  the  left  nasal  bone  came  into  line  with  the  lower 
border  of*  the  right  nasal  bone  and  then  fastened  the  two 
bones  together  with  a  metallic  suture.  The  sides  of  the 
flap  were  then  united  to  the  cheeks  and  those  of  the  frontal 
incision-  drawn  together  above  the  apex  of  the  Hap. 

The  pint-  united,  the  space  left   by  the    removal    of  the 

left  oasal  bone  was  tilled  with  bone  produced  by  the  peri- 
osteum brought  down  from  the  forehead  and  the  result 
w;i~  satisfactory. 


RHINOPLASTY. 


28  I 


C.  Al((iii»'-  ii><'<l  :i  Hap  of  similar  shape  in  a  case  in 
which  the  alee  and  septum  were  lost,  but  the  columns  re- 
mained. The  apex  of  the  triangle  was  placed  in  the 
space  between  the  eyebrows  and  the  incisions  diverged 
downward  and  outward.  With  a  narrow  tenotome  passed 
along  the  incisions  he  separated  the  skin  entirely  from  the 
nasal  bones  and  was  then  able  to  depress  it  far  enough  to 
attach  it  to  the  freshened  end  of  the  columna. 

D.  Italian  Method.  (Fig.  117.) — Tagliacozzi  made 
two  nearly  parallel  incisions  along  the  anterior  surface  of 

Fig.  117. 


Rhinoplasty.     Italian  method. 

the  arm,  their  length  and  the  distance  between  them  vary- 
ing  according  to  the  size  of  the  gap  the  Hap  was  to  fill. 
The  apex  of  the  flap  was  directed  toward  the  shoulder. 
The  intermediate  strip  of  skin  was  dissected  up,  but  left 
adherent  at  both  ends  and  a  piece  of  oiled  lint  passed 
under  it  and  kept  there  until  suppuration  was  established. 


282  PLASTIC   OPERATIONS   oy   THE   FACE. 

The  strip  was  then  cut  free  at  its  upper  end  and  dressed 
carefully  for  about  a  fortnight,  or  until  its  under  surface 
was  nearly  cicatrized.  It  was  then  considered  lit  to  lie 
applied,  having  undergone  the  necessary  shrinking  and 
thickening.  Its  edges  and  those  of  the  nasal  aperture 
were  pared  and  fastened  together  with  sutures  and  the 
arm  hound  fast  to  the  head.  When  union  had  taken 
place  between  the  two,  the  lower  end  of  the  Hap  was  cut 
loose  from  the  arm  and  its  edges  trimmed  to  the  proper 
shape. 

Graefe  did  not  let  the  flap  suppurate,  but  tried  to  get 
primary  union. 

Dr.  Thomas  T.  Sabine,  about  1880,  successfully  tilled 
by  the  implantation  of  a  linger  the  gap  left  by  the  de- 
struction of  the  nose. 


PLASTIC  OPERATIONS    UPON   THE    EYELIDS. 

In  these  operations  it  is  important  to  save  as  much  as 
possible  of  the  original  tissues,  especially  the  free  border 
of  the  lid,  the  conjunctiva,  and  the  orbicular  muscle.  As 
tin-  skin  is  thin  and  delicate,  the  flaps  must  have  broad 
bases  to  insure  their  vitality  ;  they  must  also  be  so  placed 
that  their  natural  retraction  will   not  tend  to  reestablish 

the  previous  defect. 

Blepharorrhaphy. — Suture  of  the  eyelids  has  proved  a 
very  valuable  adjunct  of  many  of  the  plastic  operations 
upon  the  eyelids,  and  has  even  taken  the  place  of  some  of 
them,  for  experience  has  shown  that  a  loss  of  substance  in 
either  eyelid  may  be  safely  allowed  to  fill  and  heal  by 
granulation  if  the  borders  of  the  lids  are  kept  fastened 
together.  The  eye  must  be  kept  closed  in  this  way  for 
six  months  or  a  year,  after  which  time  the  scar,  in  most 
cases,  -how-  no  tendency  to  retract.  When  the  time 
comes  to  separate  the  lids,  this  should,  at  first,  be  done  for 
only  half  an  inch  in  the  center,  and  the  opening  subse- 
quently enlarged  at  long  intervals  of  time,  any  indication 
of  cicatricial  retraction  being  meanwhile  watched  for. 

The  prolonged  occlusion  does  no  harm  to  the  eye;  on 


OPERATIONS    UPON  Till:  EYELIDS. 


the  contrary,  it  may  be  sufficient   in   itself  t<»  cure  a  com- 
mencing keratitis  occasioned  by  ectropion. 

Operation. — A  narrow  strip  of  conjunctiva  is  excised 
from  the  border  of  each  lid  on  the  conjunctival  side  of  the 
lashes,  beginning  and  ending  a  short  distance  from  the 


Fig.   118. 


Canthoplasty.     .1.  Straight  incision.     II.  Richet's  modification. 


commissures,  so  as  to  leave  a  space  for  the  How  of  the 

tears.  The  two  raw  surfaces  are  then  brought  together 
accurately  with  silver  sutures. 

To  separate  the  lids  afterward  a  director  should  be  en- 
tered at  the  opening  left  at  one  of  the  angles,  its  point 
pressed  against  the  center  of  the  line  of  union,  and  cut 
down  upon  between  the  two  rows  of  lashes. 

Canthoplasty. — Enlargement  of  the  palpebral  opening 
(  Fig.  118).  The  external  angle  of  the  eye  is  divided  hori- 
zontally with  scissors,  and  the  skin  and  conjunctiva  united 
along  the  sides  of  the  incision  by  three  points  of  sutures, 
one  of  them  being  placed  at  the  angle. 

Richet's  modification.'  (Fig.  lis,  11.) — Richet  marked 
out  a  small  flap  by  two  incision-  through  the  skin,  be- 
ginning at  opposite  points  on  the  upper  and  lower  lids 
near  the  outer  angle  and  meeting  at  a  point  external  to 
that  angle.  The  flap,  including  everything  except  the 
conjunctiva,  was  then  excised,  the  conjunctiva  split  hori- 
zontally, and  its  two  portions  trimmed  and  fastened  to  the 
edge  of  the  cutaneous  incisions. 

1  Anatomie  Meclico-Chirurgicale,  4th  edition,  p.  88. 


284 


PLASTIC  OPERATIONS  ON  THE  FACE. 


Blepharoplasty,  to  prevent  or  remedy — 

I.  Ectropion. — The  descriptions  will  begiven  for  the 
lower  li<l  only,  that  being  the  more  frequent  seat  of  the 
deformity. 

Wharton  Jones.  (Fig-  119.) — Wharton  Jones  in- 
cluded the  contracted  cicatrix  in  a  triangular  flap  one  inch 
high,  its  base  occupying  nearly  the  whole  length  of  the 

Fig.   11'.). 


Ectropion.    (Wharton  Jones.) 


lid  border.  By  dividing  the  bands  of  cellular  tissue,  but 
without  dissecting  up  the  flap,  he  restored  the  lid  to  its 
normal  position  and  held  it  there  by  uniting  the  edges  of 
the  incision  below,  thus  giving  it  the  form  of  a  Y- 

ALPHONSE    GrUERIN1    (Fig.    120)   made   two   incisions 


Fig,  120. 


Ectropion.    (Alphonbk  Gobrin.  ) 


forming  an  inverted  V.  the  point  of  which  lies  just  below 

the  center  of  the  i'rev  border  of  the  lid.       From  the  lower 
<  hirnrgii ■  <  >p6ratoire,  Ith  edition,  p.  318. 


OPERATIONS   I'I'oy  THE  EYELIDS. 


285 


extremities  of  these  incisions  he  made  a  third  and  fourth 
parallel  to  the  border  of  the  lid.  The  two  triangular 
flaps  bounded  by  the  1st  and  .'M,  and  the  2d  and  4th  in- 
cisions  were  then  dissected  up,  the  lid  raised  to  its  normal 
position  and  held  there  by  uniting  the  adjoining  sides  of 
these  two  flaps  in  such  a  manner  that  their  apices  and 
that  of  the  inverted  V  llict  at  a  common  point.  The  gaps 
left  by  the  removal  of  the  two  flaps  were  allowed  to  gran- 
ulate, or  covered  with  Thiersch  grafts.  For  greater  se- 
curity he  also  united  the  borders  of  the  lids  (blepharor- 
rhaphy). 

Fig.  1-21. 
^^^^ 


Ectropion.    .1.  Von  Graefe's  method.    B.  Knapp'a  method. 


Y<  >x  Graefe.  ( Fig.  121,  A.) — Make  an  incision  along 
the  border  of  the  lid  just  outside  of  the  lashes  from  the 
lachrymal  point  to  the  external  commissure.  From  each 
extremity  of  this  make  a  vertical  incision  downward  from 
one-half  to  three-quarters  of  an  inch  in  length.  These 
incisions  should  involve  only  the  skin.  Cut  off  the  upper 
inner  corner  of  this  Hap,  not  by  a  straight  incision,  but  by 
one  forming  an  angle,  as  shown  in  the  figure,  and  fasten 
this  angle  by  a  suture  to  that  formed  by  the  border  of  the 
lid  and  the  inner  vertical  incision.  Reunite  the  edges  of 
the  transverse  incision,  cutting  the  ends  of  the  sutures 
long  enough  to  reach  to  the  forehead  and  then  fastening 
them  there  with  adhesive  plaster.  The  excision  of  the 
inner  angle  of  the  flap  raises  the  eyelids  by  shortening  its 
border. 

DlEFFENBACH,  Adams,  and  Amm<>\  have  proposed 
other  methods  of  shortening  the  lid.     They  are  indicated 


286 


PLASTIC  OPERATIONS  ON  THE   FACE. 


in  Fig.  122,  whore  the  shaded  spaces  represent  the  por- 
tions  of  skin  to  be  removed,  and   the  threads  the  manner 


Fir;.   122. 


Ectropion.  A.  Dieffenbach.  H.  Adams.  C.  Amnion.  The  shaded  spaces  indi- 
cate the  portions  of  skin  removed;  the  threads  show  how  their  edges  arc  brought 
together. 

in    which    the    edges    are    afterward    brought    together. 

Adams's  excision  included  the  whole  thickness  of  the  lid. 

RlCHET.     (Fig.  123.) — Richet  made  an  incision  parallel 

to  the  border  of  the  lid,  half  an  inch  below  it,  and  extend- 


Fro.  123. 


*Ukti2S& 


I  let  ropion.     (Ri<  in  i .  | 

ing  nearly  from  one  angle  of  the  eye  to  the  other.  The 
lid,  having  been  IVccd  by  this  incision,  was  then  united  to 
the  other  (blepharorrhaphy  \. 

H<-  next  made  a  second  incision  parallel  to  the  first  and 
one-third  of  an  inch  below  it,  divided  tli<'  intermediate 
strip  of  skin  vertically  in  the  middle  and  dissected  up  its 
two  halves,  [mmediately  below  the  lower  end  of  this 
vertical  incision  h<'  removed  from  the  lower  border  oi  the 
-•■'•"iid  incision  a  V-shaped  flap  of  skin,  its  point  directed 


OPERATIONS    UPON    THE  EYELIDS. 


287 


downward.  lie  then  raised  the  two  halves  of  the  middle 
flap,  brought  them  again  into  contact  with  the  border  of  the 
lid,  excised  their  superfluous  length,  mid  united  them. 
The  sides  of  the  V  are  then  brought  together  and  the 
edges  of  the  incisions  reunited. 

Kxapp.  (Fig.  121,  B.) — Knapp  employed  the  follow- 
ing method  to  remove  an  epithelioma  occupying  the  inner 
portion  of  the  lower  eyelid,  the  free  border  of  which  was 
involved.  He  circumscribed  the  tumor  by  two  vertical 
and  two  horizontal  excisions  and  excised  it.  The  hori- 
zontal incisions  were  then  prolonged  on  both  sides,  the 
lower  external  one  being  inclined  downward  so  as  to  make 
the  base  of  the  flap  broader,  the  two  flaps  dissected  up, 
drawn  together  and  united  by  their  vertical  edges. 

BUKOW.  (Fig.  124.) — The  loss  of  substance  is  made 
triangular  in  shape,  the  apex  directed  downward  ;  the  base 

Fig.  124. 


is  then  prolonged  horizontally  outward,  and  an  equal  and 
similar  triangle  marked  out  upon  the  upper  side  of  the 
prolongation.  The  skin  contained  within  the  second  tri- 
angle is  then  excised,  and  the  irregular  flap  bounded  by 
the  outer  sides  of  the  two  triangles  and  the  prolongation 
of  the  horizontal  incision  dissected  outward  and  downward. 
and  then  moved  toward  the  median  line  until  it  cover- 
both  the  open  spaces. 

It  is  not  necessary  that  the  two  triangular  spaces  should 


288 


PLASTIC  OPERATIONS  ON  THE  FACE. 


touch  at  one  corner  ;  they  may  be  an  inch,  or  even  more, 
apart,  but  they  must  of  course  be  connected  by  the  hori- 
zontal incision. 

DieffenbajCH.  (Fig.  125.) — When  the  cicatrix  or 
tumor  was  large  Dieffenbach  gave  the  loss  of  substance  a 
triangular  shape,  the  apex  directed  downward.  He  pro- 
longed outward  the  horizontal  incision  forming  the  base  of 
the  triangle,  and  carried  another  incision  downward  and 
inward  from  its  outer  extremity.  The  quadrilateral  flap 
thus  marked  out  was  dissected   up  and  carried   inward  to 

Fjg.  12-"). 


Ectropion.      (  DlEFFEXBAI  II.  ) 


cover  the  loss  of  substance.  The  gap  left  by  its  removal 
was  then  drawn  partly  together  with  sutures,'and  the  re- 
mainder left  to  granulate. 

Indian  Method. — S&lillol  refers  the  first  blepharo- 
plasty  by  the  Indian  method  to  Yon  Graef'e  in  1809.  As 
this  was  previous  to  the  introduction  of  rhinoplasty  by  the 
same  method,  the  idea  was  probably  entirely  original  with 
Von  Oracle.  The  case  is  mentioned  in  hi-  Rhinoplastik, 
1818,  but  without  detail-.  The  flap  can  be  taken  from 
the  forehead  or  cheek  ;  it  should  be  very  large  and  should 
include  the  subcutaneous  cellular  tissue.  Fricke,  of  Ham- 
burg, took  a  vertical  Hap  from  the  temporal  region  to  re- 
store the  upper  eyelid. 

One  of  tin-  modifications  of  tin-  method,  intended  to 
obviate  the  necessity  of  dividing  the  pedicle,  i-  shown  in 
Fig.  L26,  .1. 


OPERATIONS   UPON  THE  EYELIDS. 


289 


RlCHET.  (Fig.  12<i,  B.) — The  lids  are  freed  by  two  in- 
cisions inclosing  all  the  cicatricial  (issue,  and  then  united 
(blepharorrhaphy),  the  sutures  being  cut  long  and  their 
ends  fastened  upon  the   forehead.     Two  Haps   are  then 


Fig.  126. 


Ectropion.    .1.  Modified  Indian  met 


B.  Richet. 


marked  out  as  shown  in  the  figure,  the  external  one,  (', 
raised  and  used  to  cover  the  original  loss  of  substance,  and 
the  inner  one,  I>,  used  to  fill  the  gap  occasioned  by  the 
removal  of  C 

Hasnek  d'Artha  (Fig.  127)  employed  the  following 
method  in  a  case  where  a  tumor  occupied  the  commissure 
and  inner  portion  of  each  eyelid.  He  made  a  curved  in- 
cision, a,  beginning  at  the  border  of  the  upper  eyelid  be- 
yond the  limit  of  the  tumor,  crossing  the  eyebrow  to  the 
forehead,  and  then  crossing  downward  to  terminate  near 
the  root  of  the  nose.  A  second  curved  incision,  e,  began 
at  the  same  point  as  the  first  and  was  carried  along  the 
upper  and  inner  edge  of  the  tumor  to  the  point  marked  /'. 
A  third  curved  incision,  e,  began  on  the  border  of  the 
lower  lid  beyond  the  limit  of  the  tumor  and  was  carried 
along  the  lower  margin  of  the  latter  to  the  point  /'.  A 
fourth  curved  incision,  g,  parallel  to  the  border  of  the 
lower  lid,  was  carried  from  the  point  outward  to  the  cheek. 

The  tumor  and  the  portion  of  the  lids  circumscribed  by 

the  incisions  c  and  e  were  then  removed,  and  each  of  the 

Haps  (1  and  //  dissected   up  to  its  base.      The   former  was 

lowered,  the  latter  raised,  and    the  excess  of  each  cut  off. 

19 


290 


/'/   [STIC  OPERATIONS   ON   THE   FACE. 


The  upper  border  of  the  Hap  h  formed  the  free  border  of 
the  lower  Lid,  and  the  lower  border  of  the  Hap  d  formed 
the  free  border  of  the  upper  lid  and  the  commissure  corre- 


Fig.  127 


Ectropion.     Hasner  d'Artha's  method, 


sponded  to  the  apex  of  the  flap  h.  The  skin  of  the  fore- 
head and  cheeks  was  mobilized  and  reunited  to  the  Haps 
(  Dubrueil). 

Denonvillier'a    method     "  by   exchange."      (Kig;.   128.) 
In  a  case  of  ectropion   of  the  lower  lid,  with  deviation 


Fig.  128. 


Ectropion.     Denonvillier'a  method  "  bj  exchan 

of  the  outer  angle  of  the  eve  downward,  Deuonvillier 
used  the  following  method  :  By  making  three  incisions  to 
nK't  in  the  form  of  Z.  he  marked  out  two  adjoining  tri- 
angular flaps  :  one  of  them  included  the  outer  angle  of  the 


OPERATIONS   UPON   THE   EYELIDS. 


291 


eye,  the  apex  of  the  other  was  situated  upon  the  forehead 
just  above  the  eyebrow.  lie  then  dissected  up  the  flaps, 
restored  the  angle  of  the  eve  to  its  proper  position, 
brought  the  upper  Hap  down  into  the  gap  made  by  the 
lower  incision,  and  the  lower  flap  up  into  that  made  by 
the  upper  incision. 

Ectropion  due  /<>  excess  of  the  conjunctiva  may  he  treated 
by  cauterization  of  the  conjunctiva,  or  by  excision  of  a 
portion.  The  latter  operation  is  simple  ;  a  fold  is  pinched 
up  with  forceps  and  excised  with  knife  or  scissors.  The 
edges  of  the  gap  may  then  he  brought  together  by  sutures 
or  left  to  granulate. 

2.  Entropion. — Canthoplasty  (7.  v.)  may  be  em- 
ployed to  remedy  moderate  entropion,  especially  if  it  be 
due  to  spasm  of  the  orbicularis. 

Ligature  (Fig.  147),  proposed  by  Gaillard  to  remedy 
trichiasis,  is  equally  applicable  to  the  cure  of  entropion. 

l'Ki.  129. 


Entropion  ;  ligaturi 


A  transverse  fold  is  pinched  up,  and  a  needle  carrying  a 
stout  ligature  passed  through  its  base,  shaving  the  ante- 
rior surface  of  the  cartilage.  The  ligature  is  tied  and 
allowed  to  cut  through  the  skin.  The  resulting  linear 
cicatrix  maintains  the  lid  in  the  position  given  it  by  the 
ligature. 

Uau  has  modified  this  by  placing  several  ligatures  in- 
stead of  only  one. 

Excision  or  cauterization  of  a  fold  of  the  skin  is  appli- 
cable to  cases  of  entropion  due  to  laxity  of  the  skin  of  the 
eyelid.      A    transverse  or  a   vertical    fold    is   pinched    up 


292 


PLASTIC  OPERATIONS   ON  THE  FACE. 


quite  near  to  the  margin  of  the  lid  and  excised;  the  bor- 
ders of  the  wound  are  united  by  sutures.  Instead  of  ex- 
cision, cauterization  of  the  strip  is  sometimes  used. 

Von  Graefe  (Fig.  130)  treated  a  case  of  spasmodic  en- 
tropion by  removal  of  a  triangular  piece  of  skin.  He 
made  a  cutaneous  incision  parallel  to  the  free  border  of 
the  lid  and  about  a  line  from  it,  and  excised  a  triangular 
cutaneous  flap,  the  base  of  which  occupied  the  median 
portion  of  the  first  incision.  The  sides  of  the  wound  left 
by  the  excision  of  the  triangular  piece  were  then  drawn 
together  with  sutures. 

Division  of  the  external  canthus  will  sometimes  relieve 
the  condition. 

For  spasmodic  entropion  of  the  upper  lid,  with  retrac- 
tion of  the  tarsal  cartilage,  Yon  Graefe  modified  the  op- 


Fig.  130. 


P^ig.  131. 


Entropion— lower  lid.    (Von  Gbaefe.)      Entropion— upper  lid.     (Von  Graefe.) 

eration  as  follows  (Fig.  131):  After  excision  of  the  tri- 
angular  cutaneous  flap,  he  drew  the  sides  of  the  wound 
apart,  divided  the  orbicular  muscle  horizontally  near  the 
edge  of  the  lid  and  drew  it  upward,  exposing  the  carti- 
lage. He  then  excised  a  triangular  piece  of  (he  cartilage, 
i lie  apex  being  at  its  lower  border,  taking  care  not  to  in- 
clude the  conjunctiva  in  the  dissection.  The  sides  of  the 
cutaneous  wound  were  then  drawn  together  with  three  su- 
ture-, tin'  middle  one  of  which  included  also  the  sides   "I' 

the  gap  h  ii  iii  the  cartilage. 


( >  1 7.7/  AT  In  NS   UPON   1  'Hi:  E ) '  EL  1 1  >s 


293 


Division  or  Resection  oj  the  Tarsal  (  artilage. — \\  hen 
the  entropion  is  caused  or  maintained  by  shortening  or 
incurvation  of  the  tarsal  cartilage,  the  operation  must  be 
directed  to  the  removal  of  this  cause. 

Vertical  division  at  one  or  two  points  of  the  entire 
thickness  <>f  the  lid  has  been  employed.  After  having 
Ween  divided,  the  border  of  the  lid  is  held  in  its  proper 
position  by  ligatures  passed  through  it  and  fastened  to 
the  forehead  (upper  lid)  or  cheek  (lower  lid),  while  the 
wound  fills  and  heals  by  granulation. 

A  horizontal  incision  through  the  conjunctiva  from  one 
vertical  incision  to  the  other  makes  it  easier  to  turn  the 
lid  out  and  hold  it  in  place. 

Longitudinal  Tarsotomy.  (Amnion.) — The  eyelid  hav- 
ing- been  turned  out,  a  knife  is  passed  through  it  from  the 


Fig.  132. 


Knapp's  modification  of  Pesruarres's  forceps. 

conjunctival  side,  a  quarter  of  an  inch  from  the  border  and 
on  a  line  with  the  lachrymal  point,  and  an  incision  made 
parallel  with  the  border  nearly  to  the  outer  angle.  A 
longitudinal  strip  of  skin  is  then  excised  and  the  edges  of 
the  gap  left  by  the  excision  are  drawn  together.  By  this 
means  the  free  border  of  the  lid  is  drawn  away  from  the 
surface  of  the  eye,  turning  upon  the  longitudinal  incision 
as  upon  a  hiuge. 

Excision  of  Part  of  the  Cartilage.  (StreatfeUd.)  (Fig. 
133.) 

The  eyelid  is  fixed  with  Desmarres's  forceps  (Fig.  132), 
the  flat  blade  against  the  conjunctiva,  and  an  incision  made 
parallel  to  the  border  of  the  lid  at  the  distance  of  one  line 
from  it,  and  carried  to  a  depth  sufficient  to  expose  the 


294 


PLASTIC  OPERATIONS  ON  THE  FACE. 


bulbs  of  the  eyelashes.  The  surgeon,  raising  the  edge  of 
the  skin,  passes  around  the  bulbs  to  the  tarsal  cartilage, 
and  then  makes  a  second  incision  at  a  greater 
distance  from  the  border  of  the  lid  than  the 
first  one  was,  meeting  the  first  at  its  two  ex- 
tremities and  inclosing  with  it  an  oval  strip  of 
skin.  These  two  incisions  are  carried  into  the 
cartilage,  circumscribing  a  longitudinal  wedge- 
shaped  strip,  the  apex  of  which  reaches  nearly 
to  the  conjunctival  side  of  the  cartilage.  The 
wound  is  left  to  heal  by  granulation,  with  the 
expectation  that  the  contraction  of  the  cicatrix 
will  overcome  the  entropion. 

.*}.  SYMBLEPHARON. — When  the  adhesion 
between  the  two  layers  of  the  conjunctiva  is  incomplete, 
that  is,  when  it  does  not  extend  to  the  bottom  of  the  sulcus 
between  the  lid  and  eyeball,  it  is  sufficient  to  throw  a  lig- 
ature around  it.  After  the;  ligature  has  cut  through,  the 
tabs  arc  successively  excised,  and  the  borders  of  each 
wound  drawn  together  or  left  to  heal  by  granulation.  To 
avoid  reunion  of  the  surfaces,  the  second  tab  should  not 
he  removed  until  after  the  wound  left  by  the  removal  of 
the  first  has  healed. 

When  the  adhesion  is  c plete,  hut  not  broad,  a  thread 

or  silver  wire  may  lie  passed  through  its  base  and  tied 
Loosely  around  it.  After  the  hole  made  by  the  wire  has 
cicatrized  the  adhesion  is  divided.  The  narrow  line  of 
cicatrix  left  at  the  bottom  of  the  fold  by  the  wire  favors 
the  separate  healing  of  the  two  sides  of  the  incision. 

. I /•//'*  M<th<,<l. — A  thread  is  passed  through  the  fold 
close  to  the  cornea,  and  the  symblepharoii  dissected  away 
from  the  eyeball.  Kadi  end  of  the  thread  LB  then  attached 
to  a  needle  and  passed  through  the  lid  from  within  out- 
ward ;it  the  bottom  of  the  wound.  By  drawing  upon  the 
thread  and  tying  it  outside  ih<'  lid  the  symblepharon  is 
folded  upon  itself  and  its  point  fixed  a1  the  bottom  of  the 
buIcus.  The  edges  of  the  wound  mi  the  eyeball  arc  then 
drawn  together  with  sutures,  the  conjunctiva  being  loos- 
ened by  dissection,  if  necessary. 


OPERATIONS    UPON    THE   EYELIDS. 


295 


Teates  Method.  (Figs.  I-"'.  I.  L35,  136.) — This  symble- 
pharon  is  separated  from  the  ball  of  the  eye  by  an  incision 
along  the  line  of  its  union  with  the  cornea,  and  dissected 
down  to  the  bottom  of  the  fold  as  in    Arlt's  operation,  its 


Fig.  134. 


Fig.  135. 


Symblepharon. 


B,  C.    The  flaps. 


apex,  however,  being  left  upon  the  cornea.  Two  long, 
narrow  conjunctival  Maps,  />'  and  C,  are  then  dissected  up 
on  opposite  sides  of  the  eyeball,  their  bases  directed  toward 
the  symblepharon,  their  borders  parallel  to  that  of  the 
cornea.  These  Hap-  should  not  include  the  subconjunc- 
tival tissue      The  inner  flap  B  is  brought  down  and  fast- 

Fig.   136. 


1-  Upe  in  place 


ened  to  the  denuded  surface  of  the  eyelid,  the  outer  flap  C 
covers  that  of  the  eyeball.  They  are  fastened  in  place  by 
means  of  fine  sutures,  and  the  edges  of  the  gaps  left  by 
their  removal  brought  together  in  the  same  manner. 

Ledentu's     Operation. — Where    one    lid    was    adherent 
throughout  its  entire  length,  Ledentu divided  the  adhesion 


296 


PLASTIC  OPERATIONS  <>.\    THE  FACE. 


to  a  depth  equal  to  thai  of  the  normal  fold,  dissected  a  long 
conjunctival  Hap  from  the  other  half  of  the  eye,  leaving 

it  adherent  at  both  ends,  brought  it  down  across  the  cor- 
nea, and  applied  it  to  the  raw  surface  left  on  the  eyeball 
by  the  division  of  the  adhesion.  This  Hap  should  be  at 
least  one-third  of  an  inch  broad. 

A  few  successes  have  been  obtained  by  Thiersch-graft- 
ing  of  the  raw  surface. 

4.  PteryGION.  EXCISION. — The  ptcrygion  is  pinched 
up  with  forceps,  a  knife  passed  Hatwise  under  it  close  to 
the  cornea,  and  the  portion  of  the  growth  which  corres- 
ponds to  the  latter  shaved  off.  The  edges  of  the  conjunc- 
tival wound  are  then  drawn  together  with  sutures. 

Scissors  may  be  used  instead  of  the  knife  ;  in  that  ease 
the  incision  must  begin  at  the  point  of  the  growth. 

Ligature,  Szokalski. — A  thread  is  passed  under  the 
ptervgion  by  means  of  two  small  curved  needles,  as  shown 


Fig.  1:57. 


Pterygiou  ;  ligaturi 


in  Fig.  L37.     The  thread   is  cut  close  t<>  the  needles,  and 
thus  made  to  furnish  three  ligatures,  one  at  each  end,  en- 


OPERATIONS   UPON   THE  EYELIDS.  297 

circling  the  growth  at  righi  angles  to  its  long  axis,  and  our 
in  the  middle,  encircling  its  implantation  upon  the  sclerotic. 
The  ligatures  arc  tied  tightly,  and  the  inclosed  portion 
falls  in  n  few  days. 

5.  Trichiasis. — Temporary  removal  of  the  deviated 
lashes  is  seldom  effectual.  Permanent  removal  by  destruc- 
tion of  their  bulbs,  or  excision  of  the  border  of  the  lid,  is 
now  considered  unjustifiable.  The  direction  of  the  lashes 
may  be  changed  by  operation  upon  the  lid.  The  retrac- 
tion following  excision  of  an  oval  strip  of  skin,  or  the  use 
of  ligatures  as  in  entropion,  is  sometimes  sufficient,  but  it 
may  he  necessary  to  act  more  directly  upon  the  lashes. 
Simple  splitting  of  the  external  canthus  may  be  sufficient. 

Yon  Gfraefefs  JfdhorJ. — An  incision  is  made  along  the 
free  border  of  the  lid  on  the  conjunctival  side  of  the  devi- 
ated lashes.  From  each  end  of  this  a  vertical  incision  is 
next  made  through  the  free  border  and  the  skin.  The 
flap  thus  circumscribed  and  containing  the  lashes  is  dis- 
sected up  a  short  distance.  It  is  then  easy  to  fasten  it 
with  sutures  in  such  a  position  that  the  lashes  can  no 
longer  touch  the  eyeball. 

Anagrwstakis  made  a  cutaneous  incision  parallel  to  the 
border  of  the  upper  lid  and  one-eighth  of  an  inch  from  it, 
exposed  the  orbicular  muscle  by  drawing  the  skin  up,  and 
excised  that  portion  of  it  which  corresponded  to  the  upper 
part  of  the  tarsal  cartilage.  The  lower  edge  of  the  cuta- 
neous incision  was  then  drawn  up  and  fixed  to  the  fibro- 
cellular  layer  covering  the  cartilage  by  means  of  three  or 
four  sutures,  which  were  then  allowed  to  cut  themselves 
out. 


FART   VII. 

SPECIAL    OPERATIONS. 


(MT  A  PTER   T. 

OPERATIONS  UPON  THE  EYE  AND  ITS  APPENDAGES. 

In   most  operations  upon  the    eye    the  lids  should  be 
held  open  by  an  eve-speculum  (Fig;.  138),  and  the  eye- 

Fn..   138. 


Bye-spectrum. 

hall   fixed  by  pinching-  up  a  fold  of  the  conjunctiva  with 
toothed  forceps. 

The  instillation  of  a  few  drops  of  a  4  per  cent,  solution 
of  the  hydrochlorate  of  cocaine  under  the  lids  will  make 
most  operations  painless,  but  the  sensitiveness  of  the  iris 
is  not  thereby  abolished. 

THE   CORNEA. 

Removal  of  a  Foreign  Body. — When  the  foreign  body 
has  penetrated  to  only  a  slight  depth,  it  may  be  easily  re- 

299 


31  K  I 


SPECIAL   OPERATIONS. 
Fig.  139.  Fig.  140. 


Stop  needle  and  prohe  for 
puncturing  the  cornea. 


Acer's  knife. 


THE  CORNEA.  301 

moved  with  the  point  of  a  knife  or  line  forceps;  but,  if  it 
lies  so  near  the  posterior  surface  of  the  cornea  that  there 
is  danger  of  forcing  it  through  into  the  anterior  chamber 
by  the  efforts  made  for  its  extraction,  a  lance-shaped  knife 
must  be  entered  very  obliquely  and  passed  behind  it,  be- 
tween the  layers  of  the  cornea  if  there  is  sufficient  space, 
otherwise  within  the  anterior  chamber. 

If  the  foreign  body  falls  into  the  anterior  chamber,  not- 
withstanding these  efforts  to  prevent  it,  the  surgeon  must 
wait  until  the  aqueous  humor  has  reaccumulated,  and  then 
make  an  incision  three  or  four  millimeters  in  length  at  the 
lower  portion  of  the  periphery  of  the  cornea,  in  the  hope 
that  the  foreign  body  will  be  washed  out  during  the  flow 
of  the  liquid. 

Puncture  of  the  Cornea. — This  may  be  made  with  a 
broad  needle  or  a  well-worn  Beer's  knife.  It  is  advisable 
to  employ  anaesthesia,  and  to  steady  the  eyeball  with  fixa- 
tion forceps.  The  surgeon  stands  behind  the  patient, 
raises  the  upper  lid,  and  fixes  it  against  the  margin  of  the 
orbit  with  two  ringers  of  his  left  hand,  which  also  rest 
against  the  inner  side  of  the  eyeball  and  prevent  it  from 
rotating  inward.  The  needle  or  knife  is  then  entered  a 
little  in  front  of  the  edge  of  the  cornea  at  the  outer  side. 
Its  direction  must  be  sufficiently  oblique  to  avoid  injury 
to  the  iris,  and  not  so  much  so  that  the  instrument  will 
remain  between  the  layers  of  the  cornea  and  fail  to  pene- 
trate to  the  anterior  chamber.  By  partly  withdrawing 
the  instrument  and  twisting  it  slightly,  the  incision  is 
made  to  gape  and  allow  the  escape  of  the  liquid  ;  or  a  fine 
blunt  probe  may  be  passed  into  the  incision  after  entire 
withdrawal  of  the  needle.  Subsequent  tappings  are  ef- 
fected by  reopening  the  original  wound  with  the  probe. 
Figure  157  represents  a  combined  needle  and  probe. 
The  needle  is  provided  with  a  shoulder  to  prevent  its 
introduction  to  too  great  a  depth. 

Evisceration  of  the  Globe  for  Staphyloma. — The  sclerotic 
is  incised  with  a  Beer's  knife  just  in  front  of  the  insertion 
of  the  external  rectus  ;  into  the  opening  is  passed  one 
blade  of  a  pair  of  small   blunt-pointed  scissors,  and  the 


302  SPECIAL  OPERATIONS. 

anterior  portion  of  the  globe  is  cut  away,  with  the  lens 
and  all  the  vitreous  humor.  The  wound  is  then  closed 
with  catgut  sutures  passed  through  the  conjunctiva  alone. 

THE  IRIS. 

Iridotoray. — Incision  of  the  iris  may  be  performed  for 
the  purpose  of  establishing  an  artificial  pupil.  As  its  suc- 
cess depends  upon  the  retraction  of  the  divided  fibers,  it 
should  be  undertaken  only  when  their  contractility  is  not 
interfered  with  by  too  extensive  adhesions  or  has  not  been 
destroyed  by  disease.  The  more  common  lesions  to  which 
the  operation  is  applicable  are  central  opacity  of  the 
cornea,  occlusion  of  the  pupil,  and  excessive  prolapse  of 
the  iris  after  removal  of  a  cataract;  but  the  danger  of  in- 
jury to  the  lens  is  so  great  that  the  operation  is  practically 
restricted  to  the  class  of  eases  last  mentioned. 

The  best  place  for  an  artificial  pupil  is  in  the  lower 
inner  quarter  of  the  iris,  the  second  best  in  the  lower  outer 
quarter.  As  the  portion  of  the  cornea  traversed  by  the 
knife  or  needle  is  likely  to  become  more  or  less  opaque  in 
consequence,  the  incision  in  it  should  be  made  as  far  as 
possible  from  the  point  where  the  pupil  is  to  be  created. 

Simple  Incision. — Cheselden,  who  was  the  first  to  per- 
form this  operation,  entered  a  narrow-bladed  knife  through 
the  sclerotic  just  anterior  to  the  insertion  of  the  external 
rectus,  the  point  directed  toward  the  center  of  the  globe 
of  the  eye.  After  the  point  had  penetrated  to  the  depth 
of  one-eight  li  of  an  inch  it  was  directed  forward,  passed 
through  the  iris  to  the  anterior  chamber  and  transversely 
across  the  latter,  its  edge  looking  backward.  By  pressing 
the  c(\>j;c  against  the  iris  and  withdrawing  it  a  horizontal 
incision  was  made  in  that  membrane. 

Bowman  punctured  the  cornea  midway  between  its 
center  and  external  border,  passed  a  narrow  Uunt-pointed 
knife  through  the  puncture  into  the  anterior  chamber, 
and  thence  through  the  pupil  to  the  posterior  surface  of 
the  inner  half  of  the  iris,  which  he  then  divided  by  cutting 
forward,  fhe  danger  of  injury  to  the  cornea  during  the 
last  step  of  the  operation  is  very  great. 


THE  litis.  303 

Bell1  uses  a  double-edged  needle  which  is  "introduced 
through  the  cornea  near  its  margin  ;  on  arriving  at  the 

place  where  the  pupil  ought  to  he,  one  edge  is  drawn 
against  the  iris  and  divides  it  transversely,  if  possible, 
without  injuring  the  lens." 

Wecker  proposes  simple  iridotomy  and  double  iridotomy  ; 

the  former  in  cases  of  central  opacity  of  the  cornea  or  lens, 
the  latter  when  the  pupil  has  become  obliterated  after  re- 
moval of  a  cataract,  lie  uses  a  small  lance-shaped  knife 
with  a  shoulder,  straight  or  bent  upon  the  fiat,  and  n  pair 
of  forceps-scissors. 

Simple  Iridotomy.  (Wecker.) — The  knife  is  entered  mid- 
way between  the  center  and  border  of  the  cornea  on  the 
side  opposite  to  that  on  which  the  pupil  is  to  be  made. 
As  soon  as  the  cornea  has  been  perforated  the  knife  is 
withdrawn  and  the  forceps-scissors  passed  through  the 
wound  to  the  further  border  of  the  pupil,  where  they  are 
opened  and  one  of  the  blades  passed  behind,  the  other  in 
front  of,  the  iris.  By  closing  them  sharply  the  circular 
fibers  are  divided  from  the  margin  of  the  pupil  toward  the 
periphery  of  the  iris.  The  scissors  are  then  withdrawn, 
the  iris  replaced  if  it  engages  in  the  wound,  a  few  drops  of 
a  solution  of  atropine  placed  between  the  eyelids,  and  a 
compress  applied. 

Double  Iridotomy.  (Wecker.) — The  knife  is  passed 
perpendicularly  through  the  cornea  and  iris  one  millimeter 
from  the  <?(]^v  of  the  conjunctiva,  on  the  side  toward  which 
the  obliterated  pupil  has  been  retracted  ;  its  point  is  then 
made  to  pass  along  the  posterior  surface  of  the  iris  until 
arrested  by  its  shoulder,  when  it  is  withdrawn  slowly. 
The  forceps-scissors  are  next  introduced  through  the  in- 
cision, and  one  blade  passed  behind  and  the  other  in  front 
of  the  iris  for  a  distance  of  one-quarter  of  an  inch  or  a  lit- 
tle less.  Two  successive  sections  of  the  iris  are  then  made, 
inclosing  a  triangular  Ha]),  the  apex  of  which  is  directed 
toward  the  incision  in  the  cornea.  The  pupil  is  formed  by 
the  retraction  of  this  Hap. 

Iridectomy. —  Excision  of  a  portion  of  the  iris  may  be 
1  Manual  of  Surgical  Operations,  3d  edition,  \>.    162. 


31 » 1 


S /  7.7  7.1  L    OPERA  TIOSS. 


employee]  for  the  purpose  of  creating  an  artificial  pupil 
(optical  iridectomy),  or  for  the  relief  of  tension  in  glaucoma 
or  irido-choroiditis  (antiphlogistic  iridectomy),  or  as  a  pre- 
liminary to  the  removal  of  a  cataract.  The  size  of  the 
portion  excised  is  determined  by  the  length  and  position 
of  the  line  of  the  incision  on  the  posterior  surface  of  the 
cornea  ;  the  nearer  this  is  to  the  margin  of  the  cornea  the 
larger  will  be  the  portion  of  the  iris  removed.  In  anti- 
phlogistic iridectomy,  therefore,  when  the  entire  breadth  of 
the  iris  from  the  pupil  to  its  outer  margin  should  be  re- 
moved, the  knife  must  be  entered  one  millimeter  outside 
of  the  clear  portion  of  the  cornea;  in  optical  iridectomy, 
on  the  other  hand,  the  excised  portion  should  be  small  and 
the  knife  should  be  entered  within  the  margin  of  the  cor- 
nea. In  antiphlogistic  iridectomy  at  least  one-fourth  of 
the  iris  should  be  removed,  the  piece  being  taken  from  the 
upper  segment  in  order  that  the  loss  may  be  hidden  by  the 
upper  eyelid.  In  optical  iridectomy  the  pupil  should  be 
made  on  the  inner  side  of  the  lower  segment  unless  corneal 
opacities  are  in  the  way. 


Fig.  141. 


Fig.   U± 


Iridectomy    knives. 


Operation    for    Antiphlogistic  Iridectomy. — The  instru- 
ments  required  are  a   lance-shaped   knife,  straighl   (Fig. 


THE  IRIS. 


305 


141)  or  bent  (Fig.  142),  iridectomy  forceps  (Figs.   143 
and  144),  and  scissors  curved  upon  the  flat  (Fig.  145). 


Fig.  L43. 


Fig.   1  n. 


Iridectomy  forceps  and  scissors 


[ridectomy.     [ncision  of  cornea. 


Fig.   14.">. 


The  patient  having  been  anaesthetized  and  placed  in  a 
recumbent  posture,  the  surgeon  takes  such  a  position  in 
•20 


306 


SPECIAL   OPERATIONS. 


front  of  or  behind  him  as  will  facilitate  the  making  of  the 
first  incision.  The  eye-speculum  and  fixation  forceps 
having  been  applied,  the  latter  immediately  opposite  the 
point  of  puncture,  the  knife  is  introduced  perpendicularly 
to  the  surface  of  the  sclerotic  one  millimeter  outside  of  the 
margin  of  the  cornea  and  passed  steadily  in  until  its 
point  has  entered  the  anterior  chamber  at  its  very  rim  ; 
its  direction  is  then  changed  and  it  is  carried  along  the 
anterior  surface  of  the  iris  until  its  point  reaches  the  cen- 
ter of  the  pupil,  or  until  the  length  of  the  incision  is  con- 
sidered sufficient  (Fig.  146).  By  inclining  the  point  of 
the  knife  to  each  side,  the  length  of  the  incision  in  the 
posterior  surface  of  the  cornea  may  be  made  equal  to  that 
of  the  anterior  surface. 

The  knife  is  then  withdrawn  and  the  aqueous  humor 
allowed  to  run  off  very  slowly  in  order  that  the  relief  of 
intra-ocular  pressure  may  not  be  so  sudden  as  to  lead  to 
congestion  and  hemorrhage. 

If  the  iris  does  not  now  present  in  the  wound  the  iri- 
dectomy forceps  must  he  introduced  closed  as  far  as  to 
the  margin  of  the  pupil,  which  is  then  seized  and  drawn 
out  gently  through  the  incision.  An  assistant  then  cuts 
off  with  the  curved  scissors  all  the  protruding  portion  of 


Fig.  148. 


T\  rrell's  I i<. 


I ridcetomr,     Excision  of  tin-  in 


the  iris  close  to  the  lips  of  the  wound  |  Fig.  117).  Or  the 
fixation  forceps  may  be  confided  to  the  assistant  before 
the  introducti »f  the  iridectomy  forceps,  and  the  sur- 


TEE  IRIS.  307 

geon  left  free  to  use  the  scissors  himself.  Instead  of  the 
iridectomy  forceps,  Tyrrell's  hook  (Fig.  148)  may  be 
used  to  draw  the  iris  out  through  the  incision.  It  must 
be  introduced  upon  its  side,  hooked  around  the  margin  of 
the  pupil,  and  then  its  point  must  be  turned  toward  the 
cornea  and  away  from  the  center  of  the  eyeball  so  that  it 
will  not  catch  upon  the  posterior  edge  of  the  incision 
during  its  withdrawal. 

If  any  hemorrhage  takes  place  into  the  anterior  cham- 
ber the  escape  of  blood  before  coagulation  should  be 
favored  by  separating  the  lips  of  the  incision  with  a 
curette,  and  making  gentle  pressure  upon  the  eyeball. 
The  edges  of  the  iris  must  be  carefully  replaced  with  a 
spatula  and  not  left  included  in  the  corneal  wound. 

Iridesis,  or  displacement  of  the  pupil  by  ligature.  Crit- 
chett,1  the  inventor  of  this  operation,  claims  that  by  it  the 
size,  form,  and  direction  of  the  pupil  can  be  regulated  to  a 
nicety,  and  its  mobility  preserved.  It  is  applicable  to 
numerous  groups  of  eases  in  which  the  natural  pupil,  or 
even  a  part  thereof,  is  movable,  and  has  a  free  edge;  but 
the  simplest  class  is  that  of  central  opacity  of  the  cornea, 
in  which  it  is  only  required  that  the  natural  pupil  should 
be  moved  slightly  to  one  side,  so  as  to  bring  it  opposite 
the  transparent  part  of  the  cornea.  It  has  also  been  used 
in  cases  of  conical  cornea,  to  change  the  shape  of  the  pupil 
to  that  of  a  slit  ;  and  in  a  case  where  the  pupil  had  been 
rendered  very  small  and  narrow  by  broad  synechia?, 
Critchett  made  it  large  and  almost  circular  by  drawing 
its  sides  apart  at  nearly  opposite  points. 

The  operation  is  performed  as  follows  : 

An  opening  is  made  with  a  broad  needle  through  the 
margin  of  the  cornea  close  to  the  sclerotic,  and  just  large 
enough  to  admit  the  canula  forceps.  A  small  portion  of 
the  iris  near  lint  not  close  to  its  ciliary  attachment  is  seized 
and  drawn  out  to  the  extent  considered  sufficient  for  the 
proposed  enlargement  of  the  pupil  ;  a  piece  of  fine  floss 
silk,  previously  tied  in  a  small  loop  round  the  canula  for- 
ceps, is  slipped  down,  and  carefully  tightened  around  the 
'Ophthalmic  Hospital  Reports,  Vol.  I.,  p.  -J'Jo. 


308 


SPECIAL    OPERATIONS. 


portion  of  iris  made  to  prolapse,  so  as  to  include  and 
strangulate  it  (Fig.  149).  This  manoeuvre  is  best  accom- 
plished by  holding  each  end  of  the  silk  with  a  pair  of 
small   broad-bladed  forceps,  bringing  them  exactly  to  the 


Fig.  149. 


[ridesis. 


spot  where  the  knot  is  to  be  tied,  and  then  drawing  it 
moderately  tight.  The  small  portion  of  the  iris  included 
in  the  ligature  speedily  shrinks,  leaving  the  little  loop  of 
silk,  which  may  be  removed  on  the  second  day. 

If  it  is  desired  to  make  the  pupil  extend  to  the 
periphery  of  the  iris,  the  margin  of  the  pupil  must  be 
seized  with  the  forceps  and  drawn  out  through  the  in- 
cision. In  this  case  Soelberg  Wells  prefers  a  blunt  hook- 
to  the  canula  forceps. 

Corelysis,  or  rupture  of  adhesions  uniting  the  margin  of 
the  pupil  and  the  lens.  The  operation  was  first  performed 
by  Streatfeild,  as  follows:'  He  punctured  the  cornea 
with  a  broad    needle  on   the   outer  side   near  its  margin, 

Fig.  150. 


-in  atfeild'i  Bpatula  I k. 


passed  his  Bpatula  (Fig.  1  50)  along  the  anterior  surface  of 

the  iris   to  the   pupil,  engaged   the  adhesions   in  the  notch 

'<  Ophthalmic  Hospital  Reports,  Vol.  I.,  i>.  6. 


OPERATIONS  POR  CATARACT.  309 

on  the  edge  of  the  spatula,  and  tore  them.  When  the  en- 
tire margin  of  the  pupil  was  adherent,  he  passed  the 
ueedle  along  the  surface  of  the  iris,  across  the  pupil  to  its 
opposite  margin,  and  cut  the  adhesions  at  that  point. 
Then  withdrawing  the  knife,  he  passed  the  spatula  through 
the  hole  thus  made,  and  easily  broke  up  the  remaining  ad- 
hesions. When  the  adhesions  were  too  strong-  to  be  broken 
with  the  spatula,  he  used  the  eanula  scissors.  A  few  drops 
of  a  solution  of  atropine  should  be  applied  to  the  eye,  both 
before  and  after  the  operation. 

OPERATIONS    UNDERTAKEN    FOR    THE    RELIEF    OF 
CATARACT. 

A  cataract  is  an  opacity  of  the  crystalline  lens,  or  of  its 
capsule,  or  of  both  :  the  former  being  the  much  more  com- 
mon variety.  It  may  be  hard,  soft,  or  semiliquid,  and  its 
condition,  in  this  respect,  has  an  important  bearing  upon 
the  choiee  of  a  method  of  operation.  The  lens  is  com- 
posed of  a  solid  nucleus  and  a  soft  cortex  ;  the  whole  lying- 
free  within  the  capsule  which  is  itself  attached  to  the  vitre- 
ous humor.  In  eonsequence  of  the  absence  of  adhesions 
behveen  the  lens  and  the  capsule,  moderate  pressure  is 
sufficient  to  force  out  the  former  after  the  latter  has  been 
divided. 

In  operating  upon  a  cataract,  the  patient  should  be  re- 
cumbent :  cocaine  anaesthesia  is  sufficient  except  with 
young  children  or  unruly  patients,  when  ether  may  be 
necessary.  The  other  eye  should  be  covered  with  a  band- 
age, unless  its  sight  is  entirely  lost ;  and  an  eye-speculum 
may  be  used  to  keep  the  lids  apart,  if  the  services  of  a 
trained  assistant  cannot  be  had.  The  objection  to  a  spec- 
ulum is  that  it  is  somewhat  in  the  way  of  the  knife,  can- 
not be  removed  promptly  enough,  and  is  apt  to  make 
dangerous  pressure  upon  the  eye.  If  used,  the  screw  of 
the  instrument  should  be  loosened  as  soon  as  the  incision 
has  been  made.  A  few  drops  of  a  solution  of  atropine 
should  be  placed  under  the  lids  a  short  time  before  the 
operation. 


310 


SPECIAL   OPERATIONS. 


The  methods  of  operation  may  be  classified  as: 
Depression  or  couching; 

Division,  discission,  or  solution  ; 
Extraction  ; 

Operation  for  secondary  cataract. 

Depression  or  couching,  which  was  the  original  and,  for 
many  years,  the  only  method  of  removing  cataract,  is  now 
universally  abandoned,  on  account  of  the  danger  that  the 
displaced  lens  may  set  up  inflammation  of  the  eye  by  con- 
tact with  the  other  parts,  especially  the  iris  and  ciliary 
processes,  and  thus  cause  total  loss  of  sight.  Soelberg 
Wells  states  that  about  fifty  per  cent,  of  the  eyes  thus 
operated  upon  have  been  lost  by  chronic  irido-choroiditis. 
The  operation  will  be  described,  how- 
FIG-  151.  ever,  for  the  sake  of  reference.      If  the 

puncture  is  made  in  the  sclerotic,  the 
operation  is  called  scleronyxis;  if  in  the 
cornea,  keratonyxis. 

Scleronyxis. — A  curved  couching 
needle  (Fig.  151),  its  convexity  turned 
upward,  is  passed  through  the  sclerotic 
on   the  temporal  side  about  four  milli- 


h 


Y 


Fig.  15 


<  Imiching  needl 


I  tepreflsing  cataract. 


meters  Prom  the  margin  of  the  cornea,  and  three  millime- 
ters below  the  horizontal  diameter  of  the  eye.  Its  con- 
vexity i<  then  turned  forward,  and  the  needle  carried  be- 
hind and  parallel  to  the  iris  across  to  the  upper  and  inner 


OPERATIONS  FOB  CATARACT.  311 

margin  of  the  pupil  (Fig.  152),  when  the  handle  i>  lightlj 
tilted  upward,  and  the  lens  slowly  depressed  by  the  eon- 
cave  surface  of  the  needle.  After  holding  it  in  place  for 
a  moment,  the  needle  is  slightly  rotated  to  disentangle  its 

point,  and  withdrawn. 

Some  authors  recommend  that  the  anterior  capsule 
should  l>e  formally  divided  horizontally  or  vertically 
before  the  lens  is  depressed. 

Keratonyxis. — The  needle  is  passed  through  the  cornea 
a  little  below  its  horizontal  diameter,  and  midway  be- 
tween its  center  and  margin,  and  carried  backward  and 
inward,  through  the  pupil  to  the  lens,  which  is  then  de- 
pressed as  before. 

In  the  variety  of  depression  called  redinaMorif  the 
upper  edge  of  the  lens  is  rotated  backward  about  its 
transverse  axis  at  the  same  time  that  it  is  depressed,  so 
that  its  anterior  becomes  its  superior  surface. 

Division,  Discission  or  Solution. — The  object  of  this  op- 
eration is  to  tear  open  the  anterior  capsule  with  a  fine 
needle,  and  bv  thus  bringing  the  aqueous  humor  into  con- 
tact with  the  lens  to  promote  the  gradual  softening  and 
absorption  of  the  latter.  The  selection  of  the  term  dis- 
cission was  made  in  consequence  of  an  erroneous  impres- 
sion, that  the  more  completely  the  lens  was  broken  up  at 
first  the  more  rapidly  would  the  work  of  absorption  go 
on,  and  surgeons,  therefore,  tried  to  cut  the  whole  lens 
into  fragments.  Experience  has  since  shown  that  in 
most  cases  the  absorption  must  be  gradual  and  the  oper- 
ation frequently  repeated,  only  a  small  amount  of  the 
substance  of  the  lens  being  allowed  to  come  into  contact 
with  the  aqueous  humor  on  each  occasion.  If  the  lens  is 
all  broken  up  at  once,  the  numerous  fragments  swell  and 
act  as  foreign  bodies  in  the  aqueous  humor  and  set  up  in- 
flammation in  the  iris  and  cornea,  with  immediate  arrest 
of  the  process  of  absorption.  This  operation  is  more  es- 
pecially indicated  in  the  cortical  cataract  of  children  and 
of  young  persons  up  to  the  age  of  twenty  or  twenty-five 
years,  also  in  those  forms  of  lamellar  cataract  in  which 
the  opacity  is  too  extensive  to  allow  of  much  benefit  being 


312 


SPECIAL   OPERATIONS. 


A 


Fig.  154. 


Bowman's  fine 
- 1 « 1 1  j  needle, 


derived  from  an  artificial  pupil.  After  the  age  of  thirty- 
five  or  forty  absorption  is  much  slower  and  the  iris  much 
more  irritable. 

There  are  two  methods  ol'  performing 
the  operation  ;  in  one  the  needle  is  passed 
through  the  cornea,  in  the  other  through 
the  sclerotic. 

Division  Through  the  Cornea. — The 
pupil  is  widely  dilated  with  atropine,  the 
eyelids  drawn  apart  by  an  assistant,  or 
fixed  with  the  eye-speculum,  and  a  fold 
of  conjunctiva  on  the  inner  side  of  the 
eye  seized  with  the  fixation  forceps.  A 
fine  spear-shaped  needle  with  a  shoulder 
(Fig.  153)  is  passed  through  the  outer 
lower  quadrant  of  the  cornea,  almost  per- 
pendicularly to  its  surface  at  a  point  well 
within  the  dilated  pupil,  so  that  the  iris 
shall  not  be  touched  by  the  needle.  One 
or  more  incisions,  according  to  the  effect 
desired,  are  then  made  in 
the  anterior  capsule  of  the  ^Ki-  ]:,::- 
lens,  the  needle  withdrawn,  A 

and  a  compressive  bandage 
applied.  The  operation 
may  be  repeated  as  soon  as 
all  redness  and  irritability 
of  the  eye  have  disappeared. 

Division  Through  the  Scler- 
otic. (Hays.1) — The  patient 
having  been  prepared  as  be- 
fore, the  knife-needle  (Fig. 
I  54),  with  its  cutting  edge 

upward,  is  passed  through  the  sclerotic  at  a  point  on  its 
transverse  diameter  three  or  four  millimeters  from  the 
temporal  margin  of  the  cornea,  and  perpendicularly  to  the 
surface  of  the  eyeball.     Its  direction  is  then  changed  and 

ite    point  carried   between  the  iris  and  lens  to  the  opposite 
1  American  Journal  of  Medical  Sciences,  July,  L855,  \>.  81. 


II  iv.  b  kcifi-needl: 


OPERATIONS  FOR  CATARACT.  313 

margin  of  the  pupil.  If  it  encounters  :in<l  penetrates  the 
lens  on  tlio  way,  it  will  probably  dislocate  it,  in  which 
ease  extraction  should  be  at  once  performed  :  if  the  needle 
is  pushed  into  the  lens  without  dislocating  it,  the  instru- 
ment should  he  withdrawn  until  its  point  is  free,  and  then 
pushed  on  again  in  a  better  direction. 

This  being  accomplished,  the  edge  of  the  knife  is  turned 
back  against  the  center  of  the  lens,  and  a  free  incision 
made  by  withdrawing  it  a  short  distance,  while  pressing 
its  edge  firmly  against  the  cataract. 

In  order  to  expedite  the  cure,  Wells  thinks  it  is  a  good 
plan  to  combine  division  with  extraction,  and  remove  the 
whole  cataract  by  a  linear  incision  after  it  has  been  soft- 
ened by  contact  with  the  aqueous  humor.  In  children 
this  may  be  done  within  a  week  after  the  division.  The 
same  proceeding  may  be  employed  in  cases  of  partial  cat- 
aract, the  transparent  portion  of  the  lens  being  made 
opaque  and  softened  by  the  introduction  of  the  needle. 

Extraction. — The  methods  of  extraction  may  be  classi- 
fied as — 

The  flap ; 

Von  Graefe's  ; 

The  linear ; 

The  scoop ; 

Extraction  by  suction,  and 

Removal  of  the  lens  in  its  capsule. 
Flap  Extraction. — The   common  flap  operation  is 
certainly  the    best  when   it  is  successful.      It    is    nearly 

Fig.  loo. 


Siehel's  kull'e. 


painless,  does  not  affect  the  appearance  of  the  eye  and 
leaves  a  natural  movable  pupil.  These  advantages,  how- 
ever, are  offset  by  serious  disadvantages  ;  the  great  size 
of  the  flap  involves  the  risk  of  partial  or  diffuse  suppura- 


314 


SPECIAL   OPERATIONS. 


156 


<i 


don  of  the  cornea,  accompanied  possibly  by  suppurative 
iritis  or  iridochoroiditis.  Prolapse  of  the 
iris  is  ;i  not  infrequent  complication  and  the 
after-treatment  requires  much  more  care  and 

attention.  But  at  present  this  operation  is 
performed  about  as  often  as  von  (Jraefe's 
and  with  the  hitter's  knife  instead  of*  Beer's. 

The  instruments  required  are  a  Beer's 
(Fig.  14<M  or  Sichel's  (Fig.  1  •">"))  or  von 
Graefe's  (Fig.  L59)  knife,  fixation  forceps, 
Graefe's  cystotome  and  curette  (Fig.  156) 
and  a  small  blunt-pointed  knife  or  pair  of 
scissors  for  enlarging  the  wound,  if  neces- 
sary. 

The  section  may  he  made  in  the  upper  or 
lower  half  of  the  cornea  ;  the  former  is 
rather  the  more  advantageous,  the  latter  the 
easier  of  execution. 

Operation.  ( Right  eye,  upper  section.) 
First  Stage. — Patient  recumbent,  the  op- 
erator seated  behind  him.  The  eyelids  are 
separated  by  an  assistant  standing;  at  the  pa- 
tient's left  side,  and  drawing  the  lids  gently 
apart  with  the  forefinger  of  each  hand,  with- 
out making  any  pressure  upon  the  eye.  The 
surgeon  steadies  the  eyeball  by  pinching  up 
a  fold  of  conjunctiva,  with  fixation  forceps, 
either  just  below  the  cornea,  :is  in  Fig.  1~>7, 
or  better,  perhaps,  just  below  its  prolonged 
horizontal  diameter  on  the  inner  side,  and 
draws  the  eyeball  gently  down.  lie  then 
enters  the  point  of  the  knife  at  the  outer  side 
of  the  cornea  half  ;i  millimeter  within  its 
margin,  and  just  on  its  transverse  diameter, 
and  carries  it  steadily  across  the  anterior 
chamber,  taking  care  to  keep  the  Bide  of  the 
blade  parallel  to  the  iris,  and  to  press  slightly 
downward  with  it-  back  BO  that  it  may  always  fill  the  in- 
cision  completely  and  prevent  the  escape  of  the  aqueous 


Von    Graefe's 

cystol e     and 

curette. 


OPERATIONS  FOR  CATARACT. 


315 


humor.  The  couiiterpuncture  is  made  by  the  steady  ad- 
vance of  the  knife  at  a  point  immediately  opposite  that  <>l 
entry,  the  fixation  forceps  removed,  and  the  knife  pushed 
on  in  the  same  direction  until  the  section  is  all  but  finished  ; 
when  only  a  small  bridge  of  cornea  remains  undivided  at 


Fig.  1">: 


Flap  extraction  of  cataract.     Mode  of  fixing  the  eye  ami  making  the  incision. 

its  upper  border,  the  edge  of  the  knife  is  inclined  slightly 
forward,  and  the  section  completed  by  withdrawing  the 
knife.  Close  the  eyelids  for  a  moment  before  beginning 
the  second  stage. 

Second  Stage. — The  anterior  capsule  is  next  divided 
by  introducing  the  cystotome  through  the  incision  while 
the  patient  looks  downward,  and  drawing  its  point  gently 
across  that  membrane.  Care  must  be  taken  not  to  dis- 
place the  lens  by  pressing  the  point  too  forcibly  against  it. 
Close  the  eyelids  again  for  a  moment. 

Third  Stage. — The  patient  is  again  directed  to  look 
downward,  and  steady  gentle  pressure  is  made  upon  the 
eye  with  the  forefinger  or  curette  placed  upon  the  lower 
lid  (Fig.  158).  This  pressure  should  first  be  directed 
backward  so  as  to  tip  the  upper  edge  of  the  lens  forward, 
and  then  upward  and  backward  so  as  to  force  the  lens 
through  the  dilated  pupil  into  the  anterior  chamber  and 


316 


SPECIAL   0PEUAT10NS. 


out  through  the  incision.  Ft  should  be  gentle  and  very 
steady  so  as  to  avoid  rupture  of  the  posterior  capsule  and 
escape  of  the  vitreous  humor. 

Any  portions  of  the  cortical  substance  of  the  lens  which 
may  have  been  left  behind  in  the  capsule,  or  stripped  off 
during  the  passage  of  the  lens  through  the  pupil  and  the 
incision,  must  then  he  removed,  and  the  eye  closed. 

Such  was  the  operation  employed  for  extraction  of  the 
ordinary,  hard,  senile  cataract.  The  objections  to  it,  as 
before  mentioned,  were  the  great  size  of  the  flap,  the  possi- 
ble prolapse  of  the  iris  during  the  after-treatment,  and  the 

Fig.  158. 


Flap  extraction  of  cataract.    Removal  of  the  lens  by  pressure. 

risk  of  iritis  excited  by  the  bruising  of  the  iris  during  the 
passage  of  the  lens  through  the  pupil.  Yon  Graefe  was 
the  first  to  suggest  that  this  last  risk  would  be  diminished 
by  the  excision  of  a  portion  of  the  iris,  iridectomy,  and 
on  putting  the  suggestion  into  practice  he  found  that  it 
also  enabled  him  to  remove  the  cataract  safely  through  a 
much  smaller  incision.  According  to  Mr. •Carter,1  Von 
Graefe  worked  very  sedulously  during  several  years  to 
exclude,  one  by  one,  the  chief  sources  of  the  dangers  by 
which  extraction  was  beset,  and  he  arrived  at  last  at  the 

1  Holmes' b  Surgery,  its  Principles  and  Practice,  p.  724. 


OPERATIONS  FOR   CATARAC1. 


317 


Fig.   lo<». 


Fig.  16(>. 


s-A 


Vol)    Graefe's 
cataract  knife. 


point  of  losing  only  four  eyes  out  of  one  hun- 
dred operations.  A  few  improvements  in 
detail  have  been  added  since  his  death,  but 
so  far  as  principles  and  broad  outlines  arc 
concerned  he  had  covered  the  ground.  In 
view  of  the  shortness  of  the  incision,  which 
occupies  not  more  than  one-quarter  of  the 
periphery  of  the  cornea,  the  operation  is 
generally  spoken  of  as  a  "  modified  linear 
extraction"  ;  but  the  curved  outline  of  the 
incision,  and  the  fact  that  the 
lens  is  removed  entire,  cer- 
tainly bring  it  within  the  class 
of  flap  extractions. 

Von  Graefe's  Method. 
Modified  Linear,  or  Modi- 
fied Flap  Extraction. — 
The  instruments  required,  be- 
sides the  eye-speculum  and 
fixation  forceps,  are  a  long, 
thin,  narrow  knife  (Fig.  159), 
the  blade  of  which  is  thirty 
millimeters  long  and  two  milli- 
meters wide,  iridectomy  for- 
ceps (Fig.  1  60),  scissors,  a 
cystotome  (Fig.  156),  and  a 
small  hard-rubber  or  tortoise- 
shell  curette. 

The  patient  is  etherized  and 
recumbent ;  the  surgeon  stands 
or  sits  behind  him,  holding  the 
knife  in  his  right  hand  for  the 
right  eye,  in  the  left  hand  for 
the  left  eye.  The  eyeball  is 
secured  with  the  fixation  for- 
ceps, and  the  point  of  the  knife 
is  entered  in  the  sclerotic  with 
its  edge  upward,  one  millimeter 
from  the  upper  and  outer  mar- 


lridectoinv 
forceps. 


318 


SPECL  \  L    0  PER  A  TIONS. 


gin  of  the  cornea,  and  two  millimeters  below  a  tangent  to 
its  circle  drawn  at  the  upper  end  of  its  vertical  diameter 
(Fig.  161,  A).  The  point  of  the  knife  is  at  first  directed 
toward  the  center  of  the  eyeball,  but  as  soon  as  it  has  pen- 
etrated to  the  anterior  chamber  it  is  turned  so  as  to  pass 
parallel  to  and  along  the  anterior  surface  of  the  iris  down- 
ward and  inward  about  seven  millimeters  to  a  point  cor- 
responding to  B  in  Fig.  161.  The  handle  is  then  de- 
pressed, turning  on  the  back  of  the  blade  in  the  incision, 
until  the  point  is  raised  to  the  horizontal  line  of  the  punc- 
ture, when  the  handle  must  be  inclined  somewhat  back- 
ward, and  the  point  pushed  sharply  through  the  sclerotic 


Fig.  161. 


Fig.  l()-_'. 


Iiiagrani  u>  illustrate  the  method  >if 
making  Von  Graefe's  incision. 


if  Von  Graefe's 

incision. 


and  conjunctiva  at  C}  Fig.  161.  Great  care  must  be  taken 
not  to  make  the  counter-puncture  too  far  back  in  the  scler- 
otic, a  mistake  which  may  easily  happen  if  the  blade  is 
carried  too  far  downward  and  inward  before  it  is  turned 
up  to  make  the  counter-puncture. 

The  edge  is  then  directed  forward,  and  the  incision 
completed  by  steady  advance  and  withdrawal  of  the  knife. 
The  incision  is  represented  by  the  upper,  undotted  line  in 
Fig.  1  62  ;  its  center  should  lie  at  the  juncture  of  the  cornea 
and  sclerotic.  The  little  bridge  of  conjunctiva  which  re- 
main.- at  the  center  of  the  incision  is  then  divided  in  such 
manner  as  to  leave  a  conjunctival  Hap  two  or  three  milli- 
meters l<»n^  adherent  by  its  base  to  the  cornea.  If  the 
cataract  is  large  and  hard,  it  may  be  advisable  t<>  use  a 
broader  knife,  and  make  the  points  of  puncture  and 
counter-puncture  one  millimeter  lower,  so  that  it  will  not 


OPER.  1  TIONS   FOR   < '.  1  T- 1  II. 1 '  T. 


319 


be  necessary  to  use  a  scoop  or  make  much  pressure  on  the 

eve  to  effect  the  removal  of  the  lens. 

Many  surgeons  prefer  t<>  make  the  incision  wholly  in 

the  cornea  and  close  to  it>  edge,  on  the  ground  that  the 
wound  will  heal  more  promptly  and  kindly,  and  be  ac- 
companied by  less  risk  of  loss  of  the  vitreous  or  of  pro- 
lapse of  the  iris. 

The  object  of  the  iridectomy,  which  is  the  next  step  in 
the  operation,  is  the  neutralization  of  the  circular  fibers 
rather  than  the  removal  of  a  large  portion  of  the  iris,  al- 
though some  surgeons  counsel  the  latter  on  account  of  the 
greater  security  it  gives  against  subsequent  inflammation. 
The  iridectomy  forceps  are  introduced  closed  and  opened 
slightly  when  the  point  reaches  the  margin  of  the  pupil. 
The  margin  rises  between  the  branches,  is  seized,  with- 
drawn gentlv,  and  cut  off  with  scissors  close  to  the  for- 
ceps. If  this  is  properly  done  the  angles  formed  by  the 
edges  of  the  incision  and  the  margin  of  the  pupil  will  ap- 


1 'iatriaiii  nf  the  i 


Fig.  163. 


it  and  faultv  sections  of  th 


pear  in  the  anterior  chamber  as  at  A  and  B  in  Fig.  163. 
The  portion  of  iris  removed  should  extend  quite  to  it-  cil- 
iary insertion  so  that  there  may  be  none  to  engage  in  the 
external  incision  and  prevent  its  primary  union. 

The  capsule  is  next  freely  divided  by  two  successive 
lacerations  made  with  the  cystotome.  Each  should  begin 
at  the  lower  edge  of  the  pupil  and  extend  upward,  one 
along  the  inner,  the  other  along  the  outer  side,  to  the 
upper  border  of  the  lens,  where  it  has  been  exposed  by 
the  iridectomy.  This  upper  border  should  also  be  torn  to 
an  extent  corresponding  to  the  external  incision.  This 
manoeuvre  must  be  executed  with  great  delicacy  and  light- 


320  SPECIAL   OPERATIONS. 

ness  of  touch,  in  order  that  the  lens  may  not  be  displaced 
into  the  vitreous  humor. 

The  escape  of  the  lens  is  aided  by  pressure  upon  the  cor- 
nea with  the  curette.  The  fixation  forceps  are  applied  at 
the  inner  or  outer  side,  and  the  curette  placed  upon  the 
lower  edge  of  the  cornea  and  pressed  slightly  backward 
and  upward  so  as  to  cause  the  upper  edge  of  the  lens  to 
present  in  the  section  ;  the  pressure  must  then  be  made 
directly  backward,  in  order  that  the  lens  may  be  rotated 
around  its  transverse  axis  and  tilted  well  forward  into  the 
incision.  The  curette  is  then  pushed  slowly  upward  over 
the  surface  of  the  cornea  so  as  to  follow  step  by  step  the 
delivery  of  the  lens.  Any  fragments  scraped  off  during 
the  passage  may  be  removed  by  passing  the  curette  again 
over  the  surface  of  the  cornea. 

If  the  vitreous  humor  happens  to  be  liquid  it  may 
escape  as  soon  as  the  first  incision  is  made.  In  such  a 
case  it  is  best  to  excise  a  portion  of  the  iris  and  remove 
the  lens  in  its  capsule  by  passing  a  scoop  behind  it  into 
the  vitreous  humor  and  lifting  it  out. 

Gayet  and  Knapp's  Modification. — Instead  of  lacerating 
the  capsule  as  above  described  these  surgeons  incise  it 
with  a  knife-needle  alono;  the  line  of  the  corneal  incision. 
This  is  followed  in  the  great  majority  of  cases  by  an 
unusually  uneventful  healing  free  from  iritis  and  other 
complications,  but  leaves  the  pupillary  area  occupied  by 
the  capsule  of  the  lens.  In  order  to  clear  the  pupil  the 
capsule  is  subsequently  (in  the  third  week  after  the 
extraction,  or  later)  split  with  the  knife-needle,  which 
permanently  frees  the  pupil  from  both  the  anterior  and 
posterior  capsules. 

Linear  Extraction. — Mr.  Dixon  suggests'  recti- 
linear  extraction  as  a  more  suitable  name,  because  the  in- 
cision in  the  cornea  is  a  straight  one,  in  contradistinction 
to  that  of  a  flap  extraction  which  also  forms  a  line,  but  a 
curved  one.  This  operation  is  a  modification  of  one  in- 
vented by  Gibson  in  1811,  which  had  fallen  into  entire 
disuse  before  its  ^introduction  by  Von  Graefe  in  18.r>f). 
1  Holmes's  System  of  Surgery,  Vol.  IN-,  p.  199. 


OPERATIONS  FOR  CATARACT. 


321 


It  is  designed  for  the  removal  of  soft  cataracts  through  a 
small  corneal  incision,  especially  the  cortical  cataract  of 
individuals  between  ten  and  thirty  years  of  age.  It  is 
also  often  employed  with  advantage  as  supplementary  to 
the  needle  operation.     It  is  performed  as  follows  : 

A  straight,  vertical  incision,  from  four  to  six  milli- 
meters long,  is  made  on  the  outer  side  of  the  cornea, 
about  two  millimeters  within  its  margin,  with  a  straight 
lance-shaped  iridectomy  knife,  which  is  passed  into  the 
anterior  chamber  parallel  to  the  surface  of  the  iris.  The 
capsule  is  then  freely  lacerated  with  the  cystotome,  and 
the  escape  of  the  soft  lens  facilitated  by  the  introduction 
of  a  curette  into  the  wound,  and  by  making  gentle  pres- 
sure on  the  inner  side  of  the  eye  with  the  finger.      If  por- 


Fig.  164. 


) 


lflii. 


Critcfaett's  scoop 


Bowman's  scoops. 


tions  of  the  cortex  remain  behind  the  iris  they  can  be 
brought  into  the  anterior  chamber  by  closing  the  lids  and 
making  gentle  pressure  in  circular  lines  upon  them.  If 
the  iris  protrudes,  it  must  be  gently  replaced,  or,  if  much 
bruised,  excised. 

Scoop  Extraction. — This  is  a  modification  of  linear  ex- 
traction, devised  bv  Waldau  to  obviate  the  dangers  and 
difficulties  occasioned  by  the  presence  in  the  lens  of  a  hard 
nucleus  of  greater  or  less  size.  As  the  principal  danger 
lies  in  the  bruising  of  the  iris,  Yon  Graefe  met  it  by  iri- 
dectomy, which  afterward  suggested  to  Waldau  the  idea 
of  introducing  a  scoop  and  removing  the  lens  without 
making  any  pressure  upon  the  eyeball. 

The  instruments  required  are  a  bent  lance-shaped  iri- 
dectomy knife  (  Fig.  1 4 "2 ) ,  iridectomy  forceps  and  scissors, 
21 


322 


SPECIAL   OPERATIONS. 


I  ii  rette  and  mouth- 
piece for  removal  of 
cataract  by  suet  Ion, 


and  a  thin,  flat,  .slightly  concave 
scoop.  Waldau's  scoop  resembled 
a  small  spoon.  Three  different 
kinds  are  shown  in  Figs.  164, 
165,  160. 

The  eye-speculum  and  fixation 
forceps  having  been  applied,  an 
incision,  eight  or  nine  millimeters 
long,  is  made  at  the  upper  border 
of  the  cornea  where  it  joins  the 
sclerotic.  The  corresponding  por- 
tion of  the  iris  is  removed,  and 
the  capsule  freely  torn  with  the 
cystotome,  as  before  described. 

The  scoop,  with  its  convexity 
backward,  is  then  introduced  and 
carried  carefully  down  behind  the 
lens,  until  its  extremity  has 
passed  the  lower  margin  of  the 
latter,  and  engaged  it  in  its  hook- 
like end.  It  is  then  withdrawn, 
care  being  taken  not  to  press  the 
lens  against  the  iris  and  cornea. 
If  a  little  of  the  vitreous  humor 
escapes  at  the  same  time  it  must 
be  snipped  off  and  a  compress  ap- 
plied. It  is  better  to  remove 
any  fragments  of  the  lens  that 
may  be  Left  behind  by  gently 
rubbing  the  eyeball,  rather  than 
reintroducing  the  scoop. 

Removal  by  Suction. —  Laugier 
suggested,  in  1847,  the  removal 
of  soft  cataracts  by  aspiration 
through  a  hollow  needle.     Blan- 

chol   modified  the  method  by  sub- 

atituting  a  small  canula  for  the 

needle,  and  introducing  it  through 
an  incision  in  the  cornea,  but  the 


OPERATION*  FOR   CATARACT.  323 

operation  was  not  favorably  received  until  after  it  had 
been  again  modified  by  T.  Pridgin  Teale,  Jr.,  in  1863, 
who  recommended  it  as  a  substitute  for  pressure  in  the  re- 
moval of  the  harder  portions  of  the  cataract  by  linear  ex- 
traction, and  as  supplementary  to  discission.  The  instru- 
ments required  are  a  broad  needle  and  a  suction  curette. 
The  latter  (Fig.  167)  is  described  by  Mr.  Teale1  as  con- 
sisting' of  three  parts,  a  curette,  handle,  and  suction  tube. 
"  The  curette  is  of  the  size  of  the  ordinary  curette,  but 
differs  from  it  in  being  roofed  in  to  within  one  line  of  its 
extremity,  thus  forming  n  tube  flattened  on  its  upper  sur- 
face, and  terminating,  as  it  were,  in  a  small  cup. 

The  anterior  capsule  is  first  ruptured  with  a  fine  needle 
passed  through  the  cornea,  and  then  an  opening  is  made 
with  a  broad  needle  in  the  cornea  through  which  the 
curette  is  passed  to  the  center  of  the  pupil.  The  soft 
matter  is  then  withdrawn  by  suction. 

Soelberg  Wells-  says  this  operation  has  been  employed 
at  the  Royal  London  Ophthalmic  Hospital  with  great 
success,  and  that  it  is  especially  indicated  in  cases  of  soft 
cortical  cataract.  If  the  cataract  is  somewhat  harder,  it 
is  well  to  break  it  up  with  the  needle  a  few  days  before 
attempting  to  remove  it. 

Removal  of  the  Lens  in  its  Capsule. — This  operation  is 
indicated  when  the  capsule  is  opaque,  and  whenever  the 
eye  is  exceptionally  irritable,  or  has  been  chronically  in- 
flamed, so  that  the  accidental  retention  of  any  fragments  of 
the  lens  would  be  a  source  of  serious  danger.  When  suc- 
cessful, this  method  gives  very  fine  results,  but  its  risks 
and  dangers  are  so  great  that  it  is  seldom  employed. 
Originally  introduced  by  Richter  and  Beer,  it  was  revived 
by  Sperino,  Pagenstecher,  and  Wecker.  The  former  em- 
ployed the  ordinary  flap  operation  without  laceration  of 
the  capsule.  Pagenstecher  made  a  large  Hap  in  the 
sclerotic  together  with  iridectomy.  Wecker's  method  was 
nearly  identical,  the  Incision  being  made  at  the  sclero- 
corneal  junction. 

'Ophthalmic  Eospital  Reports,  Vol.  IV.,  part  '1,  \>.  197. 

zOn  the  Discuses  oft  lie  Eye,  p.  280.      Philadelphia:  II.  C.  Leu. 


324  sri-X'IAL   OPERATIONS. 

Pagenstecher's  Method. — The  patient  having  been  thor- 
oughly anaesthetized,  a  large  flap  is  made,  usually  down- 
ward, with  a  Beer's  knife,  a  small  bridge  of  conjunctiva 
being  left  temporarily  at  its  apex.  Iridectomy  is  then  per- 
formed in  the  outer  lower  quadrant,  and  the  conjunctival 
bridge  divided  with  blunt-pointed  scissors.  Any  pos- 
terior synechia)  that  may  exist  are  torn  through  with  a 
fine  silver  hook,  and  then  the  lens  removed  in  its  capsule 
by  slight  pressure  upon  the  eyeball.  If  the  hyaloid 
membrane  should  be  ruptured  and  the  vitreous  escape, 
the  lens  must  be  removed  with  the  aid  of  a  small  scoop 
passed  in  behind  its  lower  edge. 

Secondary  Cataract. — Secondary  cataracts  vary  much  in 
thickness  and  opacity.  They  may  be  produced  by  por- 
tions of  the  lens  left  behind  and  becoming  entangled  in 
the  capsule,  by  the  deposit  of  lymph  upon  the  latter,  or 
by  the  proliferation  of  the  intracapsular  cells.  No  oper- 
ation for  secondary  cataract  should  be  performed,  until, 
at  least,  three  or  four  months  after  the  removal  of  the 
primary  cataract ;  and  if  the  pupil  has  become  contracted, 
or  if  very  extensive  posterior  synechia?  have  formed,  a 
preliminary  iridectomy  should  be  made.  Formerly  the 
plan  was  to  remove  the  opaque  and  thickened  membrane 
entirely  from  the  eye,  but  it  has  proved  very  much  safer 
and  equally  efficacious  to  make  a  small  opening  in  the 
membrane  with  a  needle. 

Cocaine  anaesthesia  is  necessary.  The  eye-speculum 
and  fixation  forceps  having  been  applied,  Bowman's  fine 
needle  (Fig.  1 5.*})  is  passed  through  the  cornea  near  its 
margin,  and  an  effort  made  to  tear  a  hole  with  it  in  the 
eciitcr  of  the  membrane  or  at  the  part  which  is  thinnest 
and  least  opaque. 

If  the  membrane  yields  before  the  needle,  or  if  it  is 
too  tough  to  be  torn,  Mr.  Bowman's  device  of  a  second 
needle  must    be  employed.      This  is  to  be  passed    through 

tli<  cornea  on  the  side  opposite  to  that  occupied  by  the 
firsl  needle,  and  then  the  operator,  transfixing  and  steady- 
ing the  membrane  with  one  needle,  tears  it  with  the  other. 

If  :niv  portion  of  the  iris  should  happen  to  lie  bruised  or 

torn,  it  inii-t  lie  excised  through  ;i  linear  excision. 


5THAS0T0MT.  325 

Dr.  Agnew  passed  a  needle  through  the  center  of  the 
membrane,  thus  steadying  l><>th  it  and  the  eye.  He  then 
made  a  linear  incision  on  the  temporal  side  of  the  cornea 
through  which  he  passed  a  small  sharp-pointed  hook,  the 
point  of  which  is  passed  into  the  same  opening  in  the 
membrane  as  the  needle.  He  next  tore  the  membrane, 
rolled  it  up  about  the  hook,  and  either  drew  it  out  alto- 
gether, or,  if  this  could  not   be  done,  tore  it  widely  open. 

OPERATION  TO   CORRECT   STRABISMUS-STRA- 
BOTOMY. 

The  tendon  of  the  internal  rectus  is  attached  to  the 
sclerotic  at  a  distance  of  five  millimeters  from  the  border 
of  the  cornea,  that  of  the  external  rectus  at  a  distance  of 
seven  millimeters.  Each  tendon  is  seven  or  eight  milli- 
meters  broad  and  is  contained  in  a  firm  sheath  resembling 
a  glove  finger,  a  prolongation  or  depression  of  the  capsule 
of  Tenon  at  the  point  where  it  is  traversed  by  the  tendon 
about  midway  between  the  anterior  margin  of  the  orbit 
and  the  posterior  pole  of  the  eyeball.  The  capsule  of 
Tenon  is  a  reflection  of  the  periosteum  of  the  orbit  from 
the  anterior  margin  of  the  latter  to  the  transverse  meridian 
of  the  eyeball  and  thence  backward  to  and  along  the  optic 
nerve  thus  constituting  the  diaphragm  which  divides  the 
orbit  into  an  anterior  and  a  posterior  loge,  the  former  of 
which  contains  the  eyeball  (received  into  a  cup-like  de- 
pression of  the  diaphragm),  the  latter  the  muscles  and  optic 
nerve.  The  capsule  sends  a  prolongation,  not  only  an- 
teriorly along  the  tendons,  but  also  posteriorly  along  the 
muscles,  and  the  union  between  the  muscle  and  sheath  is 
so  firm  that  even  after  division  of  the  tendon  the  muscle 
can  move  the  eyeball  by  acting  through  the  attachments 
of  the  capsule.  If  the  body  of  the  muscle  itself  is  di- 
vided in  the  posterior  loge,  its  influence  upon  the  move- 
ments of  the  eyeball  is  entirely  lost.  This  is  the  chief 
point  to  be  borne  in  mind  in  performing  strabotomy,  the 
tendon  must  be  divided,  not  the  muscle,  and  the  amount 
of  deviation  of  the  eye  to  be  overcome  is  the  measure  of 
the  extent  to  which  the  adjoining  tissues  must  be  divided. 


326 


SI  7.7  IA  L   OPERA  TTOXS. 


The  Operation  for  Division  of  the  Internal  Rectus  will 
alone  be  described,  that  being  the  one  commonly  required. 
The  special  instruments  required  are  :  fine-toothed  forceps 
(Fig.  168),  blunt  hook  (Fig.  169),  and  blunt-pointed 
scissors,  straight  or  curved  on  the  fiat. 

A  small  but  deep  fold  of  conjunctiva  and  subconjunctival 
tissue  is  seized  with  the  toothed  forceps  just  above  the 
lower  extremity  of  the  line  of  insertion  of  the  tendon  of  the 

Fig.  168. 


Fig.  169. 


Strabotomy  lmok. 


internal  rectus,  that  is,  two  millimeters  below  a  point  on 
the  equator  of  the  eyeball  five  millimeters  beyond  the  inner 
margin  of  the  cornea,  and  divided  with  the  scissors  just 
below  the  forceps ;  additional  snips  are  made  with  scis- 
sors  within  this  opening  until  the  tendon  or  the  sclerotic 
is  exposed.  The  surgeon  then  passes  the  point  of  the  stra- 
botomy hook,  which  should  be  somewhat  bulbous,  through 
the  opening  to  the  lower  border  of  the  tendon,  and,  keep- 
ing the  point  and  side  of  the  hook  constantly  upon  the 
sclerotic,  sweeps  it  at  first  backward,  and  then  upward  and 
forward  around  the  insertion.  When  this  manoeuvre  is 
properly  executed,  the  point  of  (lie  hook  can  be  seen  un- 
der the  conjunctiva  above  the  upper  border  of  the  tendon, 
while  it-  course  is  hidden  by  the  latter  and  prevented 
from  being  drawn  forward  to  the  margin  of  the  cornea. 
I  f  the  whole  of  the  hook  ean  be  seen  under  the  conjunctiva, 

it  i-  imt  under  the  tendon,  and  the  sweep  must  he  repeated. 
When    the   tendon  has  been  secured,  the  conjunctiva  may 


STRABOTOMY 


327 


be  pressed  hack  over  its  point,  and  the  tendon  divided 
with  scissors  close  to  its  insertion,  beginning  at  its  upper 
border;  or,  the  conjunctiva  being  left  in  place,  the  scis- 
sors may  he  passed  along  the  hook  as  a  guide,  one  blade 
below  the  tendon,  the  other  between  it  and  the  conjunc- 
tiva, and  the  tendon  divided  with  repeated  snips. 

After  the  tendon  has  heen  completely  cut  through,  the 
hook  should  he  swept  upward  and  downward  to  ascertain 
if  the  lateral  expansions  of  the  tendon  have  been  divided, 
for  the  persistence  of  even  a  few  of  them  might  he  sufficient 
to  prevent  the  success  of  the  operation. 

If  it  is  feared  that  too  great  an  effect  has  heen  produced, 
a  deep  suture  may  be  passed  through  the  tendon  and  the 


Fig.  170. 


Fig.   171. 
B' 


Method  of  estimating  the  degree 
of  squint. 


Double  operation  for  strabismus. 


conjunctiva  on  the  side  toward  the  cornea  so  as  to  limit 
the  amount  of  retraction.  The  accommodative  movements 
of  the  eye  should  be  tested  immediately  after  the  opera- 
tion, and  if  there  is  the  slightest  tendency  to  divergence 
when  the  object  is  six  or  eight  inches  distant  from  the  eye 
a  suture  should  be  inserted. 

In  the  subconjunctival  method  the  incision  in  the  con- 
junctiva is  made  below  the  insertion  of  the  tendon  on  a 
line  with  the  lower  border  of  the  cornea,  and  the  con- 
junctiva is  not  pressed  away  from  the  anterior  surface  of 
the  tendon  after  the  hook  has  been  passed  under  the  latter. 


328  SPECIAL   OPERATIONS. 

It'  the  squint  exceeds  five  <»r  six  millimeters,  as  esti- 
mated by  the  method  shown  in  Fig.  170,  both  eyes  should 
!>c  operated  upon,  hut  at  separate  times,  the  insertion  of 
tlie  internal  rectus  being  set  back  in  each  case.  Thus,  if 
the  degree  of  squint  represented  in  Fig.  171  were  cor- 
rect ed  by  setting  back  the  tendon  of  the  internal  rectus 
from  ("  to  D,  the  muscle  could  only  work  at  a  great  dis- 
advantage as  compared  with  the  internal  rectus  of  the 
other  side,  and  the  result  would  be  the  appearance  of  di- 
vergent squint  Avhenever  the  attempt  was  made  to  look  at 
an  object  near  the  eye,  because  the  muscles  could  not  turn 
the  eye  far  enough  inward.  The  condition  must  there- 
fore be  divided  between  the  two  eyes,  the  internal  rectus 
on  one  side  being  set  back  to  E,  on  the  other  side  to  E' . 

Secondary  Strabismus  following  Tenotomy  of  the  op- 
ponent is  treated  by  advancing  the  insertion  of  the  tendon 
of  the  latter  ( Prorrhaphy).  Thus,  supposing  divergent 
squint  to  have  followed  division  of  the  internal  rectus,  an 
incision  half  an  inch  long  is  made  in  the  conjunctiva  in 
the  line  of  the  horizontal  diameter  of  the  cornea,  and  the 
conjunctiva  and  subconjunctival  tissue  dissected  up  as  far 
back  as  to  the  caruncle.  A  hook  is  then  passed  around 
the  insertion  of  the  internal  rectus,  and  the  tendon  di- 
vided as  before  ;  a  suture  is  passed  through  it,  and  it  is 
drawn  toward,  and  fastened  t<»,  the  strip  of  conjunctiva 
adjoining  the  inner  border  of  the  cornea.  The  tendon  of 
the  external  rectus  must  then  be  divided  according:  to  the 
rules  laid  down  for  division  of  the  internal  rectus,  re- 
membering  that  its  attachment  to  the  sclerotic  is  distant 
seven  millimeters  from  the  edge  of  the  cornea. 

ENUCLEATION  OF  THE  EYEBALL. 

Afl  the  globe  of  the  eye  lies  somewhat  nearer  the  inner 
thai!  the  outer  side  of  the  orbit,  it  will  be  found  easier  to 
approach  it  from  the  latter  quarter.  Tillaux  '  divides  the 
conjunctiva  and  subconjunctival  fascia  with  curved  scis- 
sors along  the  attachment  of  the  external  rectus,  divides 

'  Anatomie  Topographique,  p.  190. 


OPERATIONS  UPON  LACH&YMAL   APPA&ATUS.    329 

the  tendon  of  thai  muscle,  carries  the  scissors  backward 
through  the  incision,  their  concavity  turned  toward  the 
globe,  and  cuts  the  optic  nerve  close  to  the  eyeball.  Me 
then  seizes  the  posterior  pole  of  the  globe  with  pronged 
forceps,  draws  it  out  through  the  conjunctival  incision, 
and  divides  the  remaining  conjunctival  attachments  and 
tendons  close  to  the  sclerotic. 

Other  surgeons  prefer  to  seek  and  divide  each  tendon 
in  turn  before  cutting  the  optic  nerve. 

Extirpation  of  the  Entire  Contents  of  the 
Orbit. — In  order  to  gain  additional  room,  it  is  well  first 
to  divide  the  external  commissure  of  the  lids.  A  bistoury 
is  then  entered  at  the  inner  angle,  carried  well  back  toward 
the  apex  of  the  orbit,  and  swept  along  the  floor  to  the 
outer  angle,  then  reintroduced  at  the  inner  angle,  and  car- 
ried along  the  roof  of  the  orbit  to  the  outer  angle.  The 
muscles  and  optic  nerve,  which  still  remain  attached  to 
the  eye  and  apex  of  the  orbit,  are  finally  divided  with 
curved  scissors  introduced  from  the  outer  side. 

Hemorrhage  should  be  arrested  by  packing  the  cavity 
with  antiseptic  gauze. 

OPERATIONS  UPON    THE    LACHRYMAL  APPARATUS. 

Extirpation  of  the  Lachrymal  Gland  (Fig.  172). — The 
principal  portion  of  the  lachrymal  gland  lies  just  behind 
the  junction  of  the  upper  and  outer  margins  of  the  orbit, 
enveloped  in  a  fibrous  capsule  formed  by  a  reflection  of 
the  periosteum  or  capsule  of  Tenon.  The  "  accessory  " 
portion,  together  with  the  ducts,  occupies  the  adjoining 
eyelid,  and  is  composed  of  isolated  granulations  of  granu- 
lar tissue,  which,  if  left  behind  after  removal  of  the  main 
portion,  may  continue  to  secrete  tears  and  discharge  them 
into  the  wound,  thus  causing  abscesses  and  fistuhe. 

Tillaux  '  has  pointed  out  that  the  existence  of  the  fibrous 
capsule  renders  it  possible  to  enucleate  the  gland  without 
opening  the  posterior  loge  of  the  orbit,  a  defect  in  the  older 
methods  which  included  division  of  the  external  commis- 

1  Anatomie  Topographique,  p.  237. 


330 


SPECIAL   OPERATIONS. 


sure.  Make  an  incision  one  inch  in  length  along  the  upper 
and  outer  portion  of  the  bony  margin  of  the  orbit.  Carry 
this  incision  through  all  the  soft  parts,  including  the  peri- 
osteum, down  to  the  bone;  separate  the  periosteum  from  the 
bone  at  the  under  side  of  the  incision,  and  depress  it.  The 
gland  can  then  be  distinctly  seen  through  the  thin  layer  of 
periosteum  which  separates  it  from  the  roof  of  the  orbit, 
and  can  be  removed  with  great  ease  after  the  latter  has 
been  torn  through. 

Lachrymal  Sac,  Duct,  and  Canaliculi. — The  lower  cana- 
liculus passes  downward  from  the  punctum  for  two  milli- 
meters,  then  turns   at    a   right   angle,  and    passes  horizon- 


Extirpation  of  the  lachrymal  eland,  x  skin.  /'.  Periosteum.  B.  Frontal  bone. 
<..  Lachrymal  gland.  /'.  Capsule  of  Tenon.  /.'.  Reflected  periosteum  forming  the 
capsule  or  the  gland.     /■:.  Eyeball.    O.  Conjunctiva.     /..  Eyelid.     /.  incision. 


tally  inward  to  the  lachrymal  sac,  a  distance  of  about  five 
millimeters;  the  upper  canaliculus  passes  at  first  upward 
for  two  millimeters,  and  then  downward  and  inward  to 
the  sac.  This  sharp  turn  in  the  course  of  the  canalic- 
ulus, which  is  an  obstacle  to  catheterization,  can  be  tem- 
porarily removed  by  drawing  the  border  of  the  lid  out- 
ward. The  lachrymal  sac  lies  just  behind  the  tendooculi, 
and  receives  the  canaliculi  by  a  common  duel  two  or  three 
millimeters  below  it-  upper  extremity,  their  relations  thus 
resembling  those  of  the  ileum  and  caecum,  a  resemblance 


OPERATHi.xs   UPOH  LACHRYMAL  APPARATUS.    333 


which  is  increased  by  the  presence  of  a  valve 
at  the  opening  of  the  duct  into  the  sac.  This 
valve,  described  by  Huschka,  is  thought  to 
prevent  the  reflux  of  the  contents  of  the  sac  into 
the  canaliculi.  The  direction  of  the  sat'  is 
downward  and  backward  at  an  angle  of  45°; 
it  occupies  the  lachrymal  groove,  which  is 
hounded  anteriorly  by  a  ridge  on  the  nasal  pro- 
cess of  the  superior  maxillary 
bone  at  the  inner  angle  of  the  Fig.  17:*. 
orbit,  and  is  crossed  by  the 
tendo  oculi  just  at  the  junction 
of  its  upper  and  middle  thirds. 
The  nasal  duct  is  the  direct 
continuation  of  the  sac  and 
passes  downward,  backward, 
and  outward  ;  the  combined 
length  of  the  duct  and  sac  is 
about  one  inch. 

Tt  may  become  necessary  to 
slit  a j>  tlir  canaliculus  in  order 
to  correct  a  malposition  of  the 
punctum,  or  to  facilitate  cathe- 
terization of  the  sac  and  nasal 
duct.  This  little  operation  is 
best  performed  as  followsf  right 
eye.  lower  lid)  :  The  surgeon 
stands  behind  the  patient,  who 
is  recumbent,  and  introduces  a 
tine  grooved  director)  Fig.  1  73) 
vertically  through  the  punc- 
tum for  a  distance  of  two  milli- 
meters. Then  drawing  the 
border  of  the  lid  outward  and 
somewhat  downward  with  the 
forefinger  of  his  left  hand,  he 
passes  the  director  horizontally, 
with  its  groove  upward,  along 
the    canaliculus  to    the    inner 


Fig.  174. 


Sharp-pointed 
canaliculus  di- 
rector, 


Bowman's  probe- 
pointed  canaliculus 

knife. 


332 


SPECIAL    OPERATIONS. 


side  of  the  sac.  Then,  shifting  the  director  to  the  left 
hand,  he  engages  a  sharp-pointed  knife  in  the  groove,  and 
slits  up  the  canaliculus  throughout  its  entire  length. 

Bowman's  probe-pointed  canaliculus  knife  (Fig.  174) 
may  be  substituted  for  the  director  and  knife.  It  should 
be  very  narrow,  and  its  probe  point  very  small. 

When  one  pnnctum  has  been  entirely  obliterated,  a  plan 
suggested  by  Mr.  Streatfeild  may  be  employed.  He  di- 
vides the  other  canaliculus,  passes  a  fine  director,  suita- 
bly bent,  through  the  wound  into  the  obliterated  canalic- 
ulus and  cuts  down  upon  it. 

If  the  divided  lower  canaliculus  remains  everted,  Mr. 

Fig.  17;'). 


Puncture  of  tlio  lachrymal  sac 


Critchett  advises  that  the  posterior  lip  of  the  incision  be 
cut  off  with  scissors,  ''effecting  the  treble  object  of  draw- 
ing the  canal  further  inward,  of  forming  a  reservoir  into 
which  the  tears  may  run,  and  of  preventing  reunion  of 
the  parts." 

Puncture  of  the  Sac.  (Fig.  175.) — The  three  guides  are 
the  tendooculi,the  anterior  margin  of  the  lachrymal  groove, 
and  the  direction  of  the  sac.  While  an  assistant  draws 
the  external  commissure  outward,  so  as  to  make  the  tendo 
oculi  tense  and  plainly  visible,  the  surgeon  places  his  left 
forefinger  upon  the  inner  and  lower  margin  of  the  orbit, 
BO  a-  to  have  the  bony  edge  between  the  nail  and  the  pulp 


OPERA  TIONS   UPON  L.  1  ( 'Hi:  YMA L    1  PP.  1  /,'.  1 77  x    333 

of  the  finger,  and  holding  the  knife  in  the  direction  of 
the  canal,  that  is,  nearly  parallel  to  the  median  plane, 
and  at  an  angle  of  45°  with  the  horizon,  he  passes  it 
along  his  finger-nail  into  the  sac  just  below  the  tendon. 
[t  is  important  to  mark  the  position  of  the  anterior  mar- 
gin of  the  canal  so  as  to  avoid  the  not  infrequent  mistake 
of  passing  the  knife  entirely  outside  of  the  orbit  between 
the  soft  parts  of  the  face  and  the  bone. 


CHAPTER    II. 

OPERATIONS  UPON  THE  EAR  AND  ITS 
APPENDAGES. 

OCCLUSION  OF  EXTERNAL  AUDITORY   CANAL. 

CONGENITAL  occlusion  of  the  external  meatus  is  usu- 
ally associated  with  the  absence  of  defective  development 
of  the  other  portions  of  the  auditory  apparatus.  Before 
operating  upon  such  an  occlusion,  therefore,  the  hearing 
power  should  be  tested,  and  the  permeability  or  imper- 
meability of  the  bony  portion  of  the  canal  determined  by 
puncture  with  a  needle. 

If  the  occlusion  consists  of  a  simple  membranous  dia- 
phragm it  should  be  divided  crucially,  and  the  flaps  ex- 
cised. For  deeper  and  more  extensive  obstructions  cau- 
terization with  nitrate  of  silver  is  to  he  preferred. 

INTRODUCTION  OF  SPECULUM. 
The  upper  portion  of  the  auricle  is  grasped  between  the 
ring  and  middle  fingers  of  the  left  hand  and  drawn  gently 
upward  and  backward.  Into  the  canal  thus  straightened 
the  speculum  is  introduced  with  the  right  hand,  and  then 
held  in  place  with  the  thumb  and  forefinger  of  the  left,  the 
hand  being  steadied  by  resting  its  ulnar  border  against  the 
patient's  head.  Complete  control  of  the  speculum  is  thus 
obtained,  and  it  can  be  easily  moved  about  so  as  to  bring 
every  part  of  the  tympanum  and  canal  into  view.  Light 
should  be  thrown  into  it  from  a  concave  mirror  perforated 
in  the  center  and  having  a  local  distance  of  -i\  inches. 

PARACENTESIS   OF   THE  MEMBRANA   TYMPANI. 
This  should  be  performed  while  the  head  of  the  patient 

i-  well    supported    and    a    good    light    is    thrown    upon    the 


i  'ATHETERIZA  TION  OF  EUSTAt  11IAX  TUBE.      335 

membrane  by  a  mirror  attached  to  a  forehead  band.  A 
cataract  needle  is  the  instrument  usually  employed,  and 
the  opening  should  be  made  in  the  posterior  inferior  quad- 
rant of  the  membrane. 

Tillaux  '  calls  attention  to  the  fact  that  all  the  impor- 
tant elements  of  the  membrane  occupy  its  upper  half,  and 
that  an  incision  or  rupture  near  the  handle  of  the  hammer 
may  give  rise  to  troublesome  and  even  dangerous  hemor- 
rhage.    The  lower  half  i-  less  vascular  and  less  sensitive. 

If  it  is  desired  to  maintain  the  opening  for  several  days, 
a  crucial  incision  may  lie  made,  or  a  triangular  flap  excised, 
but,  as  a  rule,  even  these  incisions  heal  very  quickly. 

CATHETERIZATION  OF  THE  EUSTACHIAN  TUBE. 

The  Eustachian  tube  is  from  one  and  a-half  to  two  inches 
long,  its  course  is  from  the  pharynx  upward,  backward, 
and  outward.  Its  pharyngeal  orifice  is  oval  and  well- 
marked  except  on  the  lower  border,  and  is  situated  just 
above  the  base  of  the  soft  palate.  Behind  the  orifice, 
between  it  and  the  posterior  wall  of  the  pharynx,  is  a  de- 
pression (Rosenmuller's  fossette)  in  which  the  beak  of  the 
catheter,  if  carried  too  far  back,  may  lodge  and  give  the 
same  sensation  to  the  surgeon's  hand  as  if  it  were  engaged 
in  the  tube.  Of  the  two  mistakes  most  frequently  made 
in  performing  catheterization,  one  is  to  pass  the  beak  of  the 
instrument  between  the  middle  and  inferior  turbinated 
bones  instead  of  along  the  floor  of  the  nasal  fossa,  and  the 
other  is  to  mistake  Rosenmuller's  fossette  for  the  orifice. 
According  to  Roosa,  the  first  mistake  is  best  avoided  by 
drawing  down  the  patient's  upper  lip  with  the  left  hand, 
and  entering  the  catheter  while  it  is  held  in  an  almost 
vertical  position,  its  concavity  directed  toward  the  median 
line.  After  the  beak  has  fairly  entered  the  meatus  the 
stem  of  the  catheter  is  gradually  raised  to  the  horizontal 
position  and  passed  backward,  its  beak  resting  on  the  floor 
of  the  meatus  close  to  the  septum,  its   convexity  upward. 

Tillaux  2  gives  the  following  directions  for  finding  the 

'Anatomie  Topographique,  p.  111. 
2  Ibid.,  p.  14n. 


336  OPERATIONS   UPON  THE  EAB. 

orifice  :  1st.  Carry  the  catheter  directly  backward,  its 
concavity  downward,  until  it  touches  the  posterior  wall  of 
the  pharynx.  2d.  Withdraw  it  until  the  beak  rests  again 
upon  the  hard  palate.  3d.  Carry  the  catheter  again  very 
gently  backward,  and  feel  with  its  beak  for  the  posterior 
border  of  the  palatine  aponeurosis,  the  firm  fibrous  con- 
tinuation of  the  palatal  bone.  This  aponeurosis  feels  as 
hard  as  bone,  and  its  posterior  border  can  be  easily  recog- 
nized by  the  softness  of  the  adjoining  tissues.  4th.  Rotate 
the  beak  of  the  catheter  outward  and  upward,  and  it  will 
enter  the  Eustachian  tube. 

OPENING  OF  THE  MASTOID  ANTRUM.1 
The  incision  begins  just  above  the  apex  of  the  mastoid 
process  and  is  carried  upward  one  and  one-half  inches 
parallel  to  the  attachment  of  the  ear,  and  about  one-half 
an  inch  behind  it.  Everything  is  divided  down  to  the 
bone,  the  periosteum  elevated,  and  the  posterior  margin  of 
the  meatus  recognized.  A  one-quarter-inch  drill  is  driven 
straight  inward  at  such  a  point  that  the  hole  it  makes  shall 
lie  as  near  as  possible  to  the  back  of  the  bony  meatus  and 
its  upper  border  be  not  more  than  one-twelfth  of  an  inch 
above  the  level  of  the  upper  margin  of  the  meatus.  It 
must  not  penetrate  deeper  than  three-quarters  of  an  inch 
or  the  external  semicircular  canal  will  be  damaged.  Deep 
perforations  back  of*  a  line  one-quarter  of  an  inch  behind 
the  posterior  margin  of  the  meatus  are  liable  to  wound  the 
lateral  sinus.  The  antrum,  which  is  about  the  size  of  a 
pen,  is  usually  reached  at  a  depth  of  three-fifths  of  an  inch. 
Or,  preferably,  the  gouge  is  used  and  the  antrum  sought 
at  the  point  above  indicated  by  freely  cutting  away  the 
bone  behind  the  meatus  including  the  posterior  wall  of 
the  latter  a-  far  a-  to  the  middle  ear. 

1  Birmingham.     Dub.  .lour.  Med  Sci.,  1891,  p.  116. 


CHAPTER    III. 

OPERATIONS  UPON  THE  MOUTH  AND 
PHARYNX. 


EXCISION  OF   THE  TONSILS  (AMYGDALOTOMY). 

The  tonsils  may  be  excised  with  a  knife  and  volsella, 
or  with  a  specially  contrived  instrument,  the  tonsilotome 
or  guillotine. 

Anaesthesia  is  not  required.  If  the  patient  is  young  or 
nervous  it  is  well  to  put  a  large  piece  of  cork  between  the 
jaws  on  each  side  to  prevent  the  mouth  from  being  closed. 
The  tonsilotome  (Fig.  176)  is  composed  of  two  rings  and 
a  fork  mounted  upon  stems  so  arranged  that  they  can  be 

Fig.   176. 


G.T/e/WA/V/V  &.  CO. 

Tonsilotome. 

worked  with  the  thumb  and  fingers  of  one  hand.  The 
two  rings  slide  flatwise  upon  each  other,  and  the  inner 
edge  of  one  is  sharp,  so  that  when  drawn  across  the  other 
it  divides  anything  lying  within  it.  The  fork  is  thrust 
forward  across  the  ring  and  drawn  away  vertically  from 
it  by  the  same  movement  which  draws  one  ring  across  the 
other.  The  rings  having  been  placed  over  the  tonsil,  the 
hook  is  driven  into  the  latter  by  a  quick  movement  of  the 
thumb  and  finger  and  draws  it  further  into  the  ring,  hold- 
ing it  tense  as  the  other  blade  cuts  across  its  base.  The 
pain  is  very  slight. 

If  the  tonsilotome  cannot  be   used  the  tonsil  must  be 
seized  with  pronged  forceps,  and  excised  between  them 
22  337 


338     OPERATIONS   UPON  MOUTH  AND  PHARYNX. 

and  the  pillars  with  a  probe-pointed  knife,  the  posterior 
portion  of  the  blade  being  guarded  with  diachylon  plaster 
so  as  to  avoid  injury  to  the  tongue. 

STAPHYLORRHAPHY. 

At  the  conclusion  of  his  historical  account  of  this 
operation  Verneuil  '  states  that  it  has  been  invented  four 
different  times.  The  earliest  record  of  the  operation  is 
found  in  a  French  book  published  in  1766,2  in  which  it 
is  said  that  a  dentist,  named  Lemonnier,  closed  a  fissure 
of  both  hard  and  soft  palates  by  freshening  its  edges  with 
a  knife  and  bringing  them  together  with  sutures.  He 
also  closed  perforations  of  the  hard  palate  by  exciting 
suppuration  of  their  borders. 

In  1791)  Eustache,  a  physician  of  Beziers,  proposed  to 
reunite  by  sutures  the  edges  of  an  incision  which  he  had 
made  the  day  before  in  the  soft  palate  of  a  patient  for  the 
purpose  of  removing  a  pharyngeal  polyp.  The  patient 
refused  the  operation.  Four  years  later,  in  1803,  Eus- 
tache sent  to  the  Academic  Royale  de  Chirurgie  at  Paris 
a  remarkable  paper  upon  congenital  fissures  in  the  soft 
palate,  and  asked  the  Society's  approval  of  the  operation 
by  which  he  proposed  to  close  them.  The  approval  was 
withheld,  and  there  is  no  record  of  any  further  steps  hav- 
ing Ween  taken. 

In  December,  1816,  Yon  (iraefe  said,  before  the  Med- 
ico-Chirurgica]  Society  of  Berlin,  that,  after  many  unsuc- 
cessful attempts  to  close  fissures  of  the  soft  palate,  he  had 
at  last  succeeded  by  drawing  the  edges  together  with 
suture.-  after  freshening  them  by  applying  muriatic  acid 
and  the  tincture  of  cantharides.  This  remark  was  re- 
ported in  the  proceedings  of  the  Society  in  Hufdand's 
Jmu-nal,  January,  1817.  Between  1816  and  L 820  Von 
Graefe  repeated  the  operation  three  times,  each  time 
without  success. 

In  L819,  Etoux,  apparently  in  entire  ignorance  of  Von 
Graefe'fi  attempt,  closed  a  fissure  by  paring  the  edges  and 

'Chirurgie  Re*paratrice,  1*77.     An.  Staphylorrhapie. 
•:Tr:iii<'  Ilea  Principalis  objetsde  MeMecine,  par  Robert. 


STAPHYLORRHAPHY 


330 


applying;  sutures.  The  case  at  once  became  very  widely 
known,  and  had  much  influence  in  popularizing  the 
operation. 

AVhen  the  extent  of  the  lesion  which  staphylorrhaphy 
is  designed  to  repair  is  considered,  the  operation  seems  to 
be  very  simple.  It  is  only  necessary  to  freshen  the  edges 
of  the  gap  and  draw  them  together  with  sutures.  Prac- 
tically, however,  the  operation  is  a  difficult  one ;  the 
parts  lie  at  a  considerable  distance  from  the  surface,  the 

Fig.   177. 


Whitehead's  modification  of  Smith's  gag. 


manipulations  are  constantly  interfered  with  by  involun- 
tary movements  of  deglutition,  the  flow  of  blood  increases 
the  obscurity,  and  the  practical  difficulties  in  the  way  of 
placing  the  sutures  are  great.  Finally,  unless  some  of 
the  muscles  of  the  palate  arc  divided,  the  tension  exerted 
by  them  upon  the  sutures  is  sufficient  to  prevent  union. 
A  great  variety  of  methods  have  been  suggested  to  over- 
come these  difficulties.  Mr.  T.  Smith  diminished  the  first 
by  the  invention  of  a  gag  (Fig.  177),  designed  to  hold  the 
jaws  apart  during  the  operation.     Van   Buren   avoided 


340     OPERATIONS   UPON  MOUTH  AND  PHARYNX. 

the  passage  of  blood  into  the  trachea  during  the  employ- 
ment of  anaesthesia  by  placing  the  patient  so  that  the  head 
should  hang  down  over  the  end  of  the  table,  and  the  blood 
escape  through  the  nose.  The  same  device  was  afterward 
employed  by  Trelat. 

Sir  William  Fergusson  relieved  the  tension  by  dividing 
the  levator  palati  on  each  side.  He  did  this  by  passing  a 
knife,  bent  at  a  right  angle,  through  the  cleft  and  dividing 
the  muscle  from  behind  forward,  without  touching  the 
mucous  membrane  on  the  anterior  face  of  the  palate.  The 
incision  should  be  perpendicular  to  the  center  of  a  line 
joining  the  hamular  process  and  the  orifice  of  the  Eusta- 
chian tube.     The  former  can  be  readily  felt  just  behind 


Hi.   180. 


Incisions. 


the  last  upper  molar  tooth,  the  latter  can  usually  be  seen 
through  the  deft  in  the  palate.  He  also  recommended 
division  of  the  palato-pharyngeus  muscle. 

S.'dillot  '  divided  the  muscle  from  before  backward. 
He  drew  the  velum  downward  and  inward  with  pronged 
forceps,  and  made  an  incision  downward  and  outward 
about  one  centimeter  above  and  on  the  outer  side  of  the 
base  of  the  uvula,  and  just  behind  and  on  the  inner  side 
of  the  last  upper  molar,  crossing  the  Levator  palati  at  right 
angles  (Fig.  17!»).  A  length  of  one  centimeter  is  usually 
1  Mi'ilrciiK-  Oplratoire,  Y<>1.  II.,  p.  65. 


SrAPUYI.iiIlIllfAPIlY. 


341 


sufficient,  but  it  must  l>c  increased  if  the  muscular  con- 
tractions persist.  The  relaxation  of  the  parts  produced 
by  these  incisions  is  shown  by  a  comparison  of  Figs.  178 
and  180.  Unless  the  incisions  are  exceptionally  large 
their  sides  remain  in   contact ;  in  any  case  they  promptly 


Division  of  muscles  >>f  soft  palate. 

reunite.  He  then  divided  the  anterior  and  posterior 
pillars,  seizing  each  in  turn  near  its  center  with  pronged 
forceps,  and  cutting  it  with  scissors. 

Mr.  George  Pollock1  has  modified  this  slightly  by  mak- 
ing the   incision  on  the  anterior    surface    of  the  palate 

1  Holmes's  System  of  Surgery,  Vol.  IV.,  p.  426. 


342     OPERATIONS   rrnx  MOTJTB  AND   PHARYNX. 

smaller.  One  (it*  the  halves  of  the  palate  is  drawn  toward 
the  median  line  by  means  of  a  ligature  passed  through  it 
near  the  base  of  the  uvula,  and  a  thin  narrow  knife  is  en- 
tered close  to  the  hamnlar  process,  a  little  in  front  of  it 
and  <>n  its  inner  side,  and  its  point  carried  upward,  back- 
ward, and  somewhat  inward,  until  it  can  be  seen  through 
the  cleft,  having  divided  on  its  way  part,  if  not  all,  of  the 
tendon  of  the  tensor  palati.  The  blade  now  lies  above 
most  of  the  fibers  of  the  levator  (Fig.  181),  and  by  rais- 
ing the  handle  and  cutting  downward,  as  the  knife  is 
withdrawn,  an  incision  of  considerable  length,  including 
the  greater  portion  of  the  levator,  is  made  on  the  posterior 
surface  of  the  palate,  while  that  on  the  anterior  surface 
need  not  be  greater  than  the  breadth  of  the  knife.  If  the 
muscle  has  been  effectually  divided  the  palate  will  be 
pendulous  and  flaccid,  and  will  not  contract  spasmodically 
when  pulled  upon.  If  any  resistance  should  persist  the 
knife  must  be  introduced  again  through  the  wound  and  the 
incision  enlarged  downward. 

Ronx  placed  his  sutures  by  putting  a  needle  at  each 
end  of  the  thread,  and  passing  them  from  behind  forward. 
Trelat  used  a  needle  fixed  upon  a  long  handle,  the  point 
bearing  the  eye  and  curved  in  the  form  of  a  U- 
After  having  been  threaded  the  point  of  the  needle  was 
passed  through  the  palate  from  behind  forward,  the 
thread  Avas  drawn  through  with  a  hook  or  forceps,  and 
the  needle,  still  threaded,  withdrawn  and  passed  in  the 
same  manner  on  the  opposite  side.  The  objection  to 
these  and  to  all  other  methods  in  which  the  needle  is 
passed  from  behind  forward,  is  that,  since  the  point  can- 
not be  seen,  it  is  very  difficult  to  make  the  punctures  on 
one  side  correspond  properly  with  those  on  the  other. 
It'  silk  sutures  are  used  each  end  may  be  passed  from  be- 
fore backward,  the  two  tied  together  loosely,  and  the  knot 

polled  back  through  one  of  the  punctures,  thus  bringing 
the  loop  behind  the  palate. 

The  method  now  usually  employed  is  the  one  intro- 
duced by  Berard.  A  curved  needle  fixed  on  a  long  han- 
dle  i-   threaded    with   a   ligature  three    feet    long,  and   its 


STAPHYLORRHAPHY 


343 


point  passed  through  the  palate  from  before  backward  ; 
the  thread  is  caught  with  hook  or  forceps  on  the  poste- 
rior side,  and  its  end  drawn  out  through  the  mouth,  the 
needle  is  then  withdrawn  and  slipped  oft"  the  thread.  It 
is  next  threaded  with  a  second  ligature  and  passed  in  the 
same  manner  through  the  opposite  half  of  the  palate,  the 
loop  seized  as  before,  drawn  through  a  short  distance,  and 
held  while  the  needle  is  withdrawn,  leaving*  the  thread 
double  in  the  puncture — the  loop  behind  the  palate,  the 
two  ends  in  front.  The  posterior  end  of  the  first  ligature 
is  then   passed   through   the  loop  of  the  second  one  (Fig. 

Fig.  1X2. 


Staphylorrhaphy  :  passing  the  sutures. 


182,  />),  and,  by  the  withdrawal  of  the  latter,  drawn 
through  the  second  puncture  (Fig.  182,  a).  Instead  of 
using  the  same  needle  to  pass  both  ligatures,  it  is  more 
convenient  to  have  two  curved  spirally  in  the  opposite  di- 
rections, one  for  each  side. 

If  silver  sutures  are  used,  thread  loops  should  be  passed 
from  before  backward  on  each  side,  one  end  of  the  wire 
engaged  in  each  and  drawn  through. 

After  a  suture  has  been  passed,  the  ends  should  be 
brought  out  through  the  mouth,  and  tied  together  for 
safety.     "When  all  have  been  passed,  the  anterior  one   is 


344     OPERATIONS   UPON  MOUTH  AND   PHARYNX. 

drawn  upon  to  bring-  the  edges  of  the  cleft  together,  and 
the  knot  tied.  The  knot  may  be  an  ordinary  square  one, 
an  assistant  holding  the  first  twist  with  dressing  forceps 
until  the  second  is  made,  or  it  may  be  a  noose,  as  shown 
in  Fig.  182,  c,  secured  by  a  second  knot.  If  silver  wire 
is  used,  it  may  be  fastened  by  twisting  it,  or  by  clamping 
a  small  lead  button  upon  it.  Verneuil  first  passes  the 
ends  of  the  wire  through  the  eyes  of  a  shirt  button,  and 
then  ties  or  twists.  He  thinks  this  favors  more  accurate 
adjustment  of  the  edges,  and  facilitates  removal  of  the 
wire. 

The  edges  of  the  cleft  are  pared  by  seizing  the  tip  of 
the  uvula  with  toothed  forceps,  making  it  tense,  entering 
the  point  of  a  narrow-bladed  knife  one  or  two  millimeters 
back  from  the  edge,  and  cutting  down  to  the  tip  ;  then 
turning  the  knife  and  cutting  up  to  the  anterior  angle  of 
the  cleft.  Care  should  be  taken  to  do  this  thoroughly. 
When  the  cleft  is  very  short  (bifid  uvula),  Nelaton  em- 
ployed the  method  already  described  under  his  name  for 
single  uncomplicated  harelip.  The  flaps  were  left  adhe- 
rent to  each  other  at  the  apex  (angle  of  the  cleft)  and  to 
the  uvula  at  their  bases,  turned  down,  and  the  raw  sur- 
faces drawn  together.  When  the  cleft  was  too  long  for 
this  he  separated  the  flaps  at  the  apex,  shortened  them 
by  trimming  off  the  free  ends,  turned  them  down,  and 
united  as  before. 

There  is  no  settled  rule  of  practice  establishing  the  order 
in  which  the  different  steps  of  the  operation  shall  be  exe- 
cuted, except  that  most  surgeons  are  agreed  upon  the  ad- 
visability of  paring  the  edges  of  the  cleft  before  passing 
the  sutures.  Mr.  Callender  recommended  that  the  muscles 
should  be  divided  a  day  or  two  before  the  attempt  to  close 
the  cleft,  on  the  ground  that  the  second  operation  is  much 
simplified  by  the  freedom  from  the  bleeding  occasioned  by 
division  of  the  muscles.  Mr.  Smith,  on  the  other  hand, 
stretched  the  palate  by  drawing  upon  all  the  sutures,  di- 
vided the  palato-pharyngeus  and  levator  palati,  and  then, 
if  the  edges  of  die  cleft  did  not  come  easily  together,  made 
two  lateral  oblique  cuts,  one  on  either  side,  above  the 


URANOPLASTY.  ">+•"> 

higher  suture,  .separating,  to  a  limited  extent,  the  soft  from 
the  margin  of  the  hard  palate. 

Bonfils,  aecording  to  Dubrueil,  elosed  an  opening  left 
at  the  upper  part  of  the  palate  by  the  partial  failure  of  an 
operation  for  staphylorrhaphy,  by  taking  a  flap  from  the 
hard  palate,  according  to  the  Indian  method  of  autoplasty 

(7-  '••)• 

URANOPLASTY. 

Verneuil  l  attributes  the  success  of  modern  uranoplastic 
operations  to  the  use  of  the  method  by  double  flaps,  ad- 
herent at  both  ends  and  brought  together  laterally  (lambeaux 
tit  pout),  and  to  the  retention  of  the  periosteum  in  the  flaps. 
He  ascribes  the  first  use  of  double  flaps  to  Dieffenbach, 
and  thinks  the  retention  of  the  periosteum  was  brought 
about  by  Ollier's  most  valuable  experimental  and  clinical 
researches  upon  the  properties  of  this  tissue.  To  Von 
Langenbeck,  by  whose  name  the  method  is  usually  known, 
he  gives  only  the  credit  of  being  the  first  to  adopt  Ollier's 
suggestion,  and  to  make  it  a  rule  of  practice. 

This  estimate  of  the  facts  does  not  seem  to  be  entirely 
correct.  It  is  true  that  Dieffenbach  used  double  lateral 
flaps,  but  a  large  part  of  the  success  of  the  modern 
method  is  due  to  the  greater  breadth  now  given  to  the 
flaps.  Tillaux  has  shown  that  the  branches  of  the  pos- 
terior palatine  artery  are  given  off  like  the  plumes  of  a 
feather,  and  that  to  avoid  division  of  these  branches,  and 
insure  the  nutrition  of  the  flap,  the  incision  must  be 
made  close  to  the  alveolar  process.  This  necessity  is  as 
absolute  in  the  case  of  a  small  perforation  as  in  that  of  a 
larger  one.  As  for  the  retention  of  the  periosteum,  Von 
Langenbeck  was  certainly  the  first  to  point  out  its  im- 
portance as  a  means  of  preventing  gangrene  of  the  flap. 
Ollier's  investigations  turned  upon  its  value  in  favoring 
reproduction  of  the  bone. 

Fissure  of  the  hard  and  soft  palate  endangers  an  in- 
fant's life  by  interfering  with  the  ingestion  of  food.  The 
exact  measure  of  this  danger  has  not  vet  been  established 

1  Chirurgie  Reparatrice,  Art.  Uranoplastie. 


346     OPERATIONS  UPON  MOUTH  AND  PSAEYNX. 

by  statistics,  hut  it  is  certainly  considerable.1  On  the 
other  hand,  all  recorded  operations  for  cleft  palate  upon 
children  less  than  one  month  old  have  terminated  fatally, 
and  those  undertaken  during;  the  first  five  or  six  months 
of  the  child's  life,  although  not  so  fatal,  show  but  few 
successes.  Billroth  and  Simon  think  the  operation  should 
be  performed  about  the  eighth  month,  but  most  surgeons 
are  agreed  upon  the  propriety  of  postponing  it  until  the 
third  or  fourth  year.  If  a  child  has  lived  six  months 
without  operation,  it  has  certainly  learned  to  overcome 
the  mechanical  difficulties  in  the  way  of  its  nourishment, 
and  there  is,  consequently,  no  reason  to  interfere  sur- 
gically until  the  second  indication  arises.  That  is  found 
in  the  defective  articulation  and  phonation  occasioned  by 
the  lesion,  and,  as  children  with  cleft  palate  do  not  begin 
to  speak  before  the  third  or  fourth  year,  the  operation 
may  be  safely  postponed  until  that  time. 

The  special  instruments  required  arc  a  speculum  oris, 
or  two  blunt  hooks  to  be  placed  at  the  angles  of  the 
month  and  fastened  together  by  a  rubber  band  passing 
behind  the  head,  pronged  forceps  with  long  handles, 
curved  needles  of  the  pattern  selected,  a  periosteum  ele- 
vator bent  at  a  right  angle  on  the  flat,  a  small  knife  simi- 
larly bent,  and  sponges  on  long  handles. 

The  edges  of  the  perforation  or  fissure  arc  first  fresh- 
ened by  the  removal  of  a  strip  one  or  two  millimeters 
thick.  An  incision  is  then  made  on  each  side  close  to  the 
gum,  extending  from  the  last  molar  tooth  forward  as  far 
as  may  be  necessary,  and  exposing  the  bone  throughout. 
The  elevator  is  introduced  into  this  incision  and  the  per- 
iosteum separated  from  without  inward,  care  being  taken 
imi  to  injure  the  palatine  arteries  at  the  anterior  and  pos- 
terior palatine  foramina. 

If  the  cleft  involves  the  soft  palate  its  sides  will  be 
found  to  round  off  toward  the  hainular  processes,  and  the 
velum  to  be  tightly  adherent  to  the  posterior  portion.    The 

flaps  cai t  lie  brought  together  until   the  attachments  of 

the  two  halves  of  the  velum  at    these  points   are    entirely 
1  Lannelongue :  M6m.  de  la  Soc.  de  Chirurgie,  L877,p.  170. 


U&ANOPLASTY. 


:u; 


Separated,  a  step  which  may  be  accomplished  by  means  of 
a  small,  curved,  sharp  elevator  introduced  through  the 
lateral  incisions,  or  by  the  bent  knife  introduced  through 
the  fissure. 

The  bleeding  during  this  stage  of  the  operation  is  very 
free,  but,  as  Ehrmann  '  has  remarked,  usually  ceases  as  soon 

Fig.  183. 


Incisions  in  uranoplasty. 

as  the  Maps  are  completely  liberated.  If  it  continues  pres- 
sure should  be  made  for  a  few  moments  with  the  finger,  or 
ice  applied.  Trelat  carries  his  incisions  farther  back, 
stopping  from  one-fourth  to  one-half  an  inch  behind  the 
posterior  border  of  the  hard  palate,  and  entirely  disregard- 
ing the  posterior  palatine  artery. 

The  flaps  are  brought  together  in  the  median  line  and 
1  M^moires  de  1'  Acad,  de  MMecine,  Vol.  XXXI. 


348     OPERATIONS   UPON  MOUTH  AND  PHARYNX. 

the  sutures  applied,  beginning  at  the  anterior  extremity  of 
the  cleft.  The  sutures  should  be  left  in  at  least  four  days 
and  then  removed,  not  all  at  once,  but  by  installments. 

If  the  fissure  is  unilateral,  the  vomer  remaining  attached 
on  the  other  side,  Yon  Langenbeck  recommends  that  the 
lateral  incision  along  the  gum  should  be  made  only  upon 
the  side  occupied  by  the  fissure.  The  flap  on  the  other  side 
should  be  dissected  up  from  the  median  line  outward. 

If  the  fissure  extends  through  the  dental  arch  and  is 
wide  at  the  point,  Rouge  r  recommends  that  one  of  the  flaps 
should  be  detached  in  front  also  and  swung  in  sideways 
upon  the  posterior  attachment  as  a  center. 

This  method  of  operating  has  practically  superseded  all 
others  for  closing  congenital  defects  in  the  hard  palate.  A 
great  number  have  been  proposed  and  more  or  less  exten- 
sively used,  but  are  now  so  seldom  resorted  to  that  only 
a  few  need  be  briefly  mentioned  for  purposes  of  reference. 

Sir  Wm.  Fergusson's  2  osteoplastic  method  consisted  in 
cutting  through  the  alveolar  margin  of  the  hard  palate  on 
each  side,  fracturing  the  anterior  extremity  of  the  strips  of 
bone  covered  with  their  muco-periosteum  and  uniting  them 
in  the  median  line.  Schonborn '''  made  a  flap  base  down 
from  the  upper  part  of  the  posterior  wall  of  the  pharynx. 
It  comprised  all  the  soft  parts  in  front  of  the  vertebra? ; 
this  was  turned  and  brought  forward  into  the  cleft.  Lan- 
nelongue  turned  down  a  flap  of  muco-periosteum  from  each 
Bide  of  the  septum  of  the  nose  and  united  the  free  edges  to 
the  freshened  margins  of  the  gap  in  the  hard  palate. 

More  recently  Davies-Colley  4  has  fashioned  muco-peri- 
osteal  flaps  of  nearly  equal  size  from  the  whole  of  the 
under  surface  of  the  rudimentary  palatine  processes  of  the 
superior  maxilla  and  palate  bones.  The  pedicle  of  flap 
No.  1  occupies  the  whole  length  of  one  side  of  the  cleft. 
The  pedicle  of  No.  2  corresponds  to  the  posterior  border 
of  :is  much  hard  palate  as  exists  on  that  side.  Xo.  1  is 
turned  over  into  the  gap,  thus  placing  its  raw  surface  in- 

1  L' L'ranoplastie  et  les  Divisions  Conduit,  fin  Palais,  1871,  p.  108. 

» British  Bled.  Jonr.,  April  1,  1874 

3 Langenbeck1  s  Arrhiv,  187!'),  Vol.  XIX.,  p.  527. 

♦British  Med.  Jour.,  October  25,  1890,  and  April  28,  1894. 


EXCISION  OF  THE  TONGUE.  349 

feriorly  ;  No.  2  is  then  slid  over  this  raw  surface  as  far 
as  possible  without  tension,  and  sutured.  The  denuded 
lateral  areas  are  left  to  heal  by  granulation. 

Acquired  losses  of  substance  in  the  hard  palate,  if  of 
any  magnitude,  are  best  treated  by  an  "obturator"  or 
vulcanized  rubber  plate,  which  a  dentist  can  fit  into  the 
roof  of  the  mouth. 

EXCISION   OF    THE    TONGUE. 

Exeision  of  the  tongue,  partial  or  complete,  may  be 
rendered  necessary  by  hypertrophy  of  the  organ  or  by  the 
presence  of  a  tumor.  The  hemorrhage  is  controlled  by 
ligation  of  the  vessels  as  they  are  divided  or  by  prelimi- 
nary ligation  of  one  or  both  lingual  arteries.  Langen- 
buch l  devised  a  method  of  so  placing  two  temporary 
ligatures  upon  the  tongue  that  bleeding  is  entirely  pre- 
vented during  the  removal  by  the  knife  of  any  portion  of 
the  anterior  half  or  even  two-thirds  of  the  member.  He 
enters  the  point  of  a  well-curved  needle  carrying  a  stout 
ligature  a  little  to  the  left  of  the  median  line  of  the 
tongue  behind  the  part  which  is  to  be  removed,  passes 
it  deeply  down  through  the  substance  of  the  tongue,  and 
brings  it  out  on  the  right  side  through  the  floor  of  the 
mouth  so  as  to  include  the  branches  of  the  lingual  artery 
in  its  loop.  To  prevent  slipping,  the  needle  is  then 
passed  through  the  edge  of  the  tongue ;  another  is  passed 
in  the  same  manner  on  the  opposite  side,  and  each  tied 
tightly.  The  ends  may  then  be  used  to  draw  the  tongue 
forward. 

It  has  also  been  suggested  that,  when  it  is  necessary  to 
operate  very  far  back  upon  the  tongue,  its  base  can  be 
brought  forward  by  dislocating  the  lower  jaw  downward 
and  forward  on  both  sides. 

The  tongue  is  drawn  well  forward,  the  tumor  or  portion 
to  be  removed  seized  with  double-pronged  forceps  and 
rapidly  excised  by  a  V-shaped  incision  made  with  a  blunt- 
pointed  bistoury  so  as  to  avoid  injury  to  the  vessels  in  the 

1  Aivliiv  fur  klinische  Chirurgie,  Vol.  XXII.,  Tart  I.,  1878,  p.  7± 


360     OPERATIONS   UPON  MOUTH  AND  PHARYNX. 

floor  of  the  mouth;  all  bleeding  points  arc  then  .secured 
and  the  sides  of  the  wound  brought  together  with  sutures. 

It' a  larger  portion,  say  a  lateral  half,  of  the  tongue  is 
in  be  removed,  the  operation  may  he  done  as  follows  : 
Two  stout  ligatures  arc  passed  through  the  tip,  one  on 
each  side  of  the  median  line,  to  he  used  to  draw  the  organ 
forward  ;  the  tip  then  raised,  the  frsenum  cut  with  scissors, 
and  the  scissors  then  pushed  along  under  the  tongue  and 
mucous  membrane  to  free  them  as  far  hack  as  necessary. 
Then  the  tongue  is  split  along  the  median  line,  from  be- 
fore backward,  completely  freed  from  the  underlying  parts 
by  tearing  with  the  finger,  the  mucous  membrane  of  the 
floor  divided  with  the  scissors,  and  the  posterior  section 
made  with  knife  or  scissors. 

Complete  through  the  Mouth. — This  operation 
has  been  extensively  employed  by  Whitehead,1  and  bears 
his  name.  He  does  not  practise  a  preliminary  ligation  of 
the  lingual  arteries,  but  secures  them  as  they  are  divided. 

The  mouth  is  made  as  aseptic  as  possible  and  the  face 
and  neck  shaved  and  cleaned.  The  lingual  artery  on 
each  side  is  ligated  ;  and  through  these  incisions,  which 
may  be  extended  if  necessary,  any  enlarged  or  suspicious 
glands,  including  one  or  both  submaxillaries,  are  removed. 
The  wounds  are  then  closed  and  dressed  antiscptically. 

After  this  the  patient's  head  is  placed  in  a  more  or  less 
erect  position  with  a  slight  inclination  forward,  to  allow 
the  blood  to  escape  from  the  mouth.  The  jaws  are  held 
well  apart  with  a  suitable  mouth-gag  and  a  ligature 
passed  through  the  tongue  in  the  median  line  about  an 
inch  from  the  tip.  With  this  the  tongue  is  drawn  out 
and  up,  while  first  the  frsenum  and  then  the  anterior 
pillar  of  the  fauces  are  divided  by  blunt-pointed  scissors. 
With  short  snips  of  the  scissors  all  the  muscles  with  the 
overlying  mucous  membrane  on  the  under  surface  of  the 
tongue  are  cut  on  a  plane  with  the  lower  border  of  the 
inferior  maxilla  and  as  far  back  as  the  safety  of  the  epi- 
glottis permit.-.  It  may  be  necessary  to  draw  the  lower 
incisor  teeth  and  thus  gain  more  room  for  manipulating 
1  Uncet,  L881,  Vol.  I.,  p.  698. 


EXCISION  OF  THE  TONGUE  351 

the  scissors.  The  tongue  is  then  drawn  upward  by  the 
ligature  passed  through  it.-  substance  and  the  posterior 
section  completed  with  knife  or  scissors.  The  dorsalis 
linguae  vessels  can  be  readily  secured  in  the  stump. 

Regnoli's  Method. — Regnoli,  of  Pisa,  published  in 
1838  the  description  of  a  method  by  which  he  success- 
fully removed  the  anterior  portion  of  the  tongue.  He 
made  a  semicircular  incision  through  the  skin  along  the 
lower  border  of  the  jaw,  beginning  and  ending  at  the 
angle.-,  and  added  a  second  one  to  it  in  the  median  line, 
extending  to  the  hyoid  bone.  The  tegumentary  flaps 
were  dissected  back,  and  the  muscles  divided  at  their  at- 
tachments to  the  inferior  maxilla.  The  tongue  was  then 
drawn  down  through  the  large  opening  thus  made,  its 
anterior  portion  readily  excised,  and  the  wound  closed. 
Billroth  has  revived  and  modified  Regnoli's  operation  and 
employed  it  in  several  eases.  It  has  the  advantage  of 
furnishing  free  drainage,  allowing  the  wound  to  he  treated 
antiseptically,  and  facilitating  the  removal  of  implicated 
lymphatic  gland-. 

Billroth'*  Method. — A  semicircular  incision  is  made 
along  the  lower  border  of  the  inferior  maxilla  from  one 
angle  to  the  other.  The  flap,  containing  the  skin,  fascia, 
and  platysma,  is  diss ected  back  and  the  lingual  arteries 
tied  beneath  the  hyoglossus  muscle,  as  described  on  page 
54. 

Enlarged  or  suspicious  glands,  including  the  submaxil- 
lary and  sublinguals,  are  dissected  out.  After  transfixing 
the  tip  of  the  tongue  with  a  ligature  to  prevent  its  falling- 
back  and  closing  the  opening  of  the  larynx,  a  knife  is 
thrust  up  through  the  floor  of  the  mouth  close  behind  the 
symphysis  and  swept  backward  on  both  sides  as  far  as  the 
anterior  pillars  of  the  fauces.  It  should  divide  the  mu- 
cous membrane  and  muscles  attached  to  the  jaw  near 
enough  to  the  bone  to  clear  all  disease  and  yet  leave  suffi- 
cient tissue  to  permit  the  divided  muscles  to  be  at  least 
partially  sutured  in  position  again. 

After  the  attachment-  of  the  geniohyoid,  geniohyo- 
glossus,  and  digastric  muscles  have  been  severed,  together 


352      OPERATIONS   UPON  MOUTH  AND  PHARYNX. 

■with  the  anterior  part  of  the  hyoglossus,  the  tongue  is 
drawn  out  through  this  gap  and  excised.  A  drain  is  in- 
troduced, the  muscles  sutured  in  position,  and  the  wound 
closed. 

Lateral  Supea-hyoid  Method.  (Kocher.1)  (Fig. 
184.) — This  method  has  for  its  object  the  very  thorough 
removal  of  all  diseased  tissues  of  the  tongue  and  pharynx 
and  all  infected  glands  in  the  neck.     Preliminary  laryngo- 

Fig.  184. 


Removal  of  the  tongue.     K.  [tocher's  incision.    S.  S6dillot's  incision'. 

tracheotomy  is  advantageous  to  facilitate  the  operation 
and  permit  antiseptic  treatment  of  the  wound. 

The  incision  is  made  from  the  under  border  of  the  lower 
jaw  near  the  symphysis,  in  the  direction  of  the  anterior 
belly  of  the  digastric,  to  the  hyoid  bone,  thence  along  its 
greater  cornu,  and  then  upward  to  the  angle  of  the  jaw  ; 
after  division  oi*  the  platvsma  and  fascia  I  he  triangular 
Hap  is  turned  up. 

The  submaxillary  fossa  is  then  emptied  by  removal  of 
1  Deutsche  Zeiteehrift  furChir.,  1880,  134. 


EXCISION  OF  THE  TONGUE.  353 

the  submaxillary  and  diseased  lymphatic  glands,  the  facial 
and  lingual  arteries  and  veins  having-  been  divided  be- 
tween double  ligatures. 

The  larynx  and  oesophagus  are  then  covered  with  a 
sponge  forced  in  behind  the  tongue,  and  an  incision  made 
into  the  floor  of  the  month  bv  cutting-  through  the  mylo- 
hyoid  muscle  close  to  the  jaw,  and  carried  along  the  bone 
as  far  as  may  be  necessary. 

The  tongue  is  now  freely  accessible  through  the  wound, 
and  can  be  drawn  out  through  it  and  split,  and  cut  oif  as 
near  its  base  as  is  desirable,  or  it  can  be  entirely  removed 
in  the  same  manner,  the  opposite  lingual  artery  being 
readily  secured  when  divided.  The  side,  and  even  the 
posterior  part  of  the  pharynx,  are  also  accessible. 

The  tracheotomy  tube  should  be  retained,  the  wound 
packed  with  antiseptic  gauze,  and  the  patient  fed  through 
an  oesophageal  tube. 

S^dillot's  Method.  (Fig.  184.) — Sedillot,  comment- 
ing upon  Regnoli's  ease,  expresses  the  opinion  that  the  ex- 
cision could  have  been  accomplished  quite  as  readily 
through  the  mouth,  and,  as  he  also  found  by  experiments 
upon  the  cadaver  that  the  tongue  cannot  be  brought  far 
enough  forward  through  such  an  opening  to  facilitate  ex- 
cision at  or  near  its  base,  he  suggested  and  employed 
division  of  the  inferior  maxilla  in  the  median  line  as  a 
preliminary  operation. 

One  of  the  median  incisor  teeth  on  the  lower  jaw  hav- 
ing been  drawn,  an  incision  is  made  in  the  median  line 
from  the  free  border  of  the  lower  lip  to  the  hyoid  bone, 
and  the  jaw  sawn  through  in  the  line  of  the  incision,  or, 
better,  by  two  oblique  lines  forming  a  =»,  the  apex  di- 
rected to  one  side.  The  attachment  of  the  genio-hyo-glossus 
muscles  to  the  bone  are  next  divided,  the  two  halves  of 
the  jaw  drawn  apart,  the  tongue  pulled  forward  and  to  one 
side,  and  its  attachments  to  the  hyoid  bone  divided  on  the 
other  side,  in  doing  which  the  lingual  artery  is  divided 
and  must  be  tied  at  once.  The  tissues  on  the  other  side 
are  then  divided  in  a  similar  manner,  and  the  other  lingual 
23 


354      OPERATIONS   UPON  MOUTH  AM)  PHARYNX. 

artery   having  been  tied  the  remaining  attachments  are 
severed  and  the  tongue  removed. 

The  divided  maxilla  is  fastened  tog-ether  again  with 
silver  sutures  passed  through  holes  pierced  in  it  with  a 
drill,  the  sides  of  the  incision  in  the  lip  accurately  ad- 
justed to  each  other,  and  the  lower  angle  of  the  wound 
left  open  for  drainage. 

The  bone  has  sometimes  been  divided  on  the  side  in- 
stead of  in  the  median  line. 

Yon  Langenbeck  makes  an  incision  from  the  angle  of 
the  mouth  vertically  down  to  the  thyroid  cartilage. 
Through  this  the  submaxillary  and  lymphatics  are  extir- 
pated, the  digastric  and  hyoglossus  muscles  cut  through, 
the  lingual  artery  tied,  and  the  jaw  sawn  obliquely  in 
front  of  the  masseter  from  above  downward  and  back- 
ward. After  drawing  apart  the  segments  the  mucous 
membrane  is  severed  from  the  inner  surface  of  the  poste- 
rior one  as  far  back  as  the  anterior  pillar  of  the  fauces. 
Through  this  gap  not  only  the  tongue  but  also  the  tonsil 
and  soft  palate  can  be  removed  if  necessary.  The  oper- 
ation is  concluded  like  Sedillot's. 

Billroth's  modification  of  this  consists  in  dividing  the 
jaw  and  overlying  soft  parts  on  both  sides,  and  turning 
down  the  intermediate  chin  segment. 

Crespi  and  Bastianelli '  have  still  further  modified 
Langenbeck's  operation  as  follows  :  An  incision  is  carried 
vertically  down  through  the  middle  of  the  lower  lip  and 
chin  t<>  the  lower  border  of  the  jaw,  along  the  latter  hori- 
zontally to  near  the  angle,  and  thence  vertically  down  tor 
about  an  inch  to  the  anterior  border  of  the  sterno-mastoid 
muscle.  The  soft  parts  arc  separated  from  the  outer  sur- 
face of  the  jaw  to  within  an  inch  of  the  insertion  of  the 
masseter,  the  facial  and  lingual  arteries  ligatcd,  the  sali- 
vary  and  lymphatic  glands  removed,  and  the  jaw  divided 
obliquely  from  behind  forward  in  front  of  the  second  mil- 
iar tooth.  This  affords  access  to  the  retrobuccal  and  phar- 
yngeal region,  and  permits  of  removal  of  the  tonsil  and 
adjoining  parts. 

■Centralb.  f.  Chir.,  1890,  p.  556. 


SALIVARY  FISTULA.  355 

DIVISION  OF  THE  FRjENUM. 

The  tip  of  the  tongue  is  raised  upon  the  handle  of  a 
director,  in  the  slit  of  which  the  frsenum  is  engaged,  and 
divided  with  curved  scissors  close  to  the  director.  Only 
the  semi-transparent  edge  of  the  constricting  hand  should 
he  cut,  and  then  the  rest  torn  by  pressing  the  tongue  up 
toward  the  roof  of  the  mouth.  If  the  ranine  vessels 
should  chance  to  be  divided  the  bleeding  can  be  controlled 
by  torsion  or  ligation  or  by  touching  the  points  with 
nitrate  of  silver,  or,  if  necessary,  with  the  actual  cautery. 
J.  L.  Petit  reported  a  case  of  suffocation  caused  by  the 
tongue  falling  back  upon  the  glottis  after  division  of  the 
frsenum,  and  (inerin  mentions  another. 

RANULA. 

The  anterior  wall  of  the  cyst  should  be  caught  up  with 
toothed  forceps  and  excised.  A  director  should  be  passed 
at  intervals  between  the  sides  of  the  incision  to  prevent 
reunion,  and  the  filling  up  of  the  sac  may  be  hastened  by 
painting  its  interior  with  nitric  acid  or  tincture  of  iodine. 
In  some  cases  it  is  sufficient  to  pass  a  thread  or  wire  seton 
through  the  cyst. 

SALIVARY  FISTULA. 

Salivary  fistula  communicating  directly  with  portions  of 
the  parotid  gland  can  usually  be  closed  by  cauterization 
and  compression,  but  when  the  fistula  communicates  with 
Steno's  duct  the  cure  is  much  more  difficult.  If  the  distal 
portion  of  the  duct  is  still  permeable  a  leaden  wire  may  be 
passed  through  it  from  the  mouth  into  the  proximal  por- 
tion of  the  duet.  The  saliva  will  follow  the  wire,  and  if 
the  fistula  does  not  close  spontaneously  its  edges  should 
be  pared  and  brought  together  with  sutures.  The  orifice 
of  the  duct  is  readily  found  opposite  the  second  upper 
molar  tooth. 

When  the  distal  portion  of  the  duet  is  obliterated  sev- 
eral methods  may  be  employed.  One  is  that  of  Deguise, 
and   consists   in    the   formation   of  a   new   channel    in    the 


356     OPERATIONS   UPON  MOUTH  AND  PHARYNX. 

cheek  for  the  saliva  ;  another  is  that  of  Van  Bnren,  and 
consists  in  the  bodily  transfer  of  the  fistulous  orifice  from 
the  outer  to  the  inner  surface  of  the  cheek. 

Deguise's  Method.  —  Deguise  made  a  puncture 
through  the  fistulous  opening  obliquely  backward  to 
the  inner  surface  of  the  cheek  and  passed  one  end  of 
a  leaden  wire  through  it  ;  he  next  made  through  the  same 
opening  a  second  puncture  directed  obliquely  forward, 
brought  the  other  end  of  the  wire  through  it  and  tied  the 
two  ends  together.  The  loop  of  the  wire  being  thus 
drawn  into  the  fistula  the  saliva  followed  its  two  branches 
into  the  mouth,  and  the  fistula  healed  at  once.  Some 
surgeons  use  a  silk  ligature  and  tie  it  tightly  so  as  to 
cut  through  the  tissues  included  in  the  loop.  Agnew's 
method  of  doing  this  is  by  the  passage  of  a  curved  needle 
around  the  duct  from  within  the  mouth. 

Van  Bikex  '  cured  a  salivary  fistula,  the  result  of  a 
gunshot  wound,  by  passing  two  fine  silver  wires  through 
the  skin  at  opposite  points  on  its  edge,  then  isolating  the 
duct  and  fistulous  opening  for  half  an  inch  by  dissection 
backward  from  the  latter,  making  an  incision  through  the 
wound  to  the  inner  side  of  the  cheek,  drawing  the  fis- 
tulous opening  through  it,  and  fastening  it  there  by 
means  of  the  wires.  The  gap  left  on  the  cheek  was  then 
closed  with  fine  silver  sutures. 

The  duct  was  so  short,  the  fistula  being  an  inch  behind 
the  anterior  margin  of  the  masseter,  that  it  could  not  be 
brought  quite  to  the  inner  surface  of  the  cheek.  The  wires, 
however,  which  were  left  in  place  until  the  fifth  week, 
kept  open  a  track,  which  became  permanent,  for  the  pas- 
gage  of  the  saliva  from  the  end  of  the  duct  to  the  mouth. 

■New  York  Medical  Journal,  Vol.  I.,  p.  •">•!,  and  Contributions  i<> 
Practical  Surgery,  1865,  p.  205. 


C  HA  PT  E  R     I  V. 

OPERATIONS  PERFORMED  UPON  THE  NECK. 

BRONCHOTOMY. 

This  is  a  general  term  covering  operations  undertaken 
to  open  the  larynx  or  cervical  portion  of  the  trachea.  These 
operations  are  :  Laryngotomy,  tracheotomy,  and  laryngo- 
tracheotomy.  Laryngotomy  is  further  subdivided  into  xii/)- 
hyoid  pharyngotomy  or  laryngotomy  (called  supra-laryn- 
geal  bronchotomy  by  Sedillot,  and  indirect  laryngotomy  by 
Planchon),  thyroid  laryngotomy  or  thyrotomy,  erico-thyroid 
laryngotomy,  and  tracheotomy,  which  is  further  subdivided 
into  high  and  low,  depending  upon  whether  the  trachea  is 
opened  above  or  below  the  isthmus  of  the  thyroid  gland. 
The  names  indicate  the  points  at  which  the  opening  is 
made  into  the  air-passages. 

Sub-hyoid  Pharyngotomy  or  Laryngotomy. — This  opera- 
tion, originally  performed  upon  animals  by  Bichat  for  the 
purpose  of  studying  the  movements  of  the  vocal  cords, 
was  afterward  proposed  by  Yidal  to  give  access  to  an 
abscess  situated  in  the  glotto-epiglottidean  folds,  and  by 
Malgaigne  to  allow  the  removal  of  a  foreign  body  lodged 
in  the  upper  part  of  the  larynx.  It  is  also  applicable  to 
the  removal  of  polyps  situated  at  the  same  point  and  not 
accessible  through  the  mouth.  Follin  thus  removed  ten 
from  the  anterior  surface  of  the  arytenoid  cartilages. 

The  shoulders  arc  raised  and  the  head  extended.  A 
transverse  incision  two  inches  long,  its  center  in  the 
median  line,  is  made  through  the  skin  immediately  below 
the  hyoid  bone,  and  the  platysma,  scerno-hyoid,  and  thyro- 
hyoid muscles,  and  thyro-hyoid  membrane  divided.  The 
mucous  membrane  lying  between  the  epiglottis  and  the 
base  of  the  tongue  then  presents  in  the  incision,  is  drawn 

357 


358  OPERATIONS   UPON  THE  NECK. 

downward  with  forceps,  and  opened  with  the  knife  or 
scissors.  The  epiglottis  is  then  seized  with  a  hook  or 
pronged  forceps  and  drawn  out  through  the  wound,  freely 
exposing  the  larynx  to  view. 

Velpeau  made  the  first  incision  in  the  median  line, 
divided  the  thy ro-h void  membrane  transversely,  and  then 
plunged  the  knife  backward  and  downward,  making  a  ver- 
tical incision  in  the  base  of  the  epiglottis  through  which 
he  passed  the  blades  of  a  pair  of  forceps  and  withdrew  the 
foreign  body. 

Aplavi/n  '  has  modified  this  operation  as  follows  :  With 
the  head  well  extended  the  trachea  is  opened  and  plugged 
by  a  tampon-can ula — a  tracheotomy  tube  surrounded  by 
a  rubber  bag,  which  is  inflated  after  its  introduction  till 
it  fills  the  lumen  of  the  trachea.  The  pharynx  is  incised 
transversely  as  above  described  and  the  hyoid  bone  cut 
through  with  scissors  on  each  side  from  one-half  to  three- 
quarters  of  an  inch  in  front  of  its  extremities.  Jf  there 
i-  fear  of  wounding  the  lingual  vessels  a  part  of  the  hyo- 
glossus  muscle  is  cut  close  above  the  hyoid  bone  and  the 
vessels  recognized  and  drawn  up.  By  raising  this  segment 
of  bone  and  depressing  the  thyroid  cartilage,  pretty  free 
access  can  be  obtained  to  the  parts  close  around  the  open- 
ing of  the  larynx. 

At  the  conclusion  of  the  operation  the  mucous  mem- 
brane is  sutured  first  ;  then  external  to  it  a  silk  suture  is 
passed  on  each  side  through  the  skin  and  upper  border  of 
the  thyroid  cartilage  behind  and  over  the  hyoid  bone  about 
one-half  an  inch  in  front  of  its  points  of  division.  After 
uniting  the  thyro-hyoid  membrane  and  overlying  soft 
part-  the  two  silk  ligatures  are  knotted  externally  and 
thn-  prevent  undue  tension  on  the  other  sutures. 

Thyroid  Laryngotomy  or  Thyrotomy. —  In  this  operation 
the  thyroid  cartilage  is  divided  vertically  in  the  median 
line,  between  the  anterior  attachments  of  the  vocal  cords. 
It  i-  suitable  for  the  removal  of  foreign  bodies  or  polyps 
from  the  interior  of  the  larynx  and  for  fractures,  stenosis, 

or  disease  of  i  his  organ. 

1  Aivhiv  f  klin.  Chir.,  Vol.  XLL,  p.  324. 


BRONCHOTOMT.  359 

The  head  is  well  extended,  or  allowed  to  hang  from 
the  vdgv  of  the  table.  A  preliminary  tracheotomy  and 
nluerfiring  of  the  trachea  may  be  necessary. 

Stead  vino-  the  larynx  with  the  thumb  and  forefinger  of 
his  left  hand,  the  surgeon  makes  an  incision  along  the  pro- 
jecting angle  of  the  thyroid  cartilage  in  the  median  line, 
from  its  upper  border  to  the  cricoid  cartilage.  As  soon 
as  the  crico-thyroid  membrane  is  exposed,  he  makes  a 
small  opening  in  it  near  its  upper  border  and  passes  one 
blade  of  a  strong  blunt-pointed  pair  of  scissors  through  it 
to  the  upper  border  of  the  larynx,  keeping  exactly  in 
the  median  line,  and  thus  divides  the  thyroid  cartilage 
throughout  its  entire  length.  Or  a  grooved  director  may 
be  passed  through  the  opening  made  in  the  crico-thyroid 
membrane,  and  the  cartilage  divided  upon  it  with  a 
curved  bistoury.  Or,  again,  the  division  may  be  made 
with  the  knife,  layer  by  layer,  from  before  backward  : 
but  whenever  possible  the  upper  border  of  the  larynx 
should  be  left  uncut  to  preserve  the  relation  of  the  vocal 
cord>. 

The  conoid  and  thvro-hvoid  ligaments  and  tliyro-hyoid 
membrane  must  often  be  separated  to  a  greater  or  less 
extent  from  the  upper  and  lower  border  of  the  thyroid 
cartilage  to  permit  its  lateral  halves  to  be  retracted  suffi- 
ciently to  expose  thoroughly  the  cavity  of  the  larynx. 

At  the  conclusion  of  the  operation  the  wound  may 
either  be  closed  immediately  with  silk  or  silver-wire 
sutures,  or  left  open  and  packed  for  a  couple  of  days. 

Crico-thyroid  Laryngotomy. — In  this  operation  the  open- 
ing is  made  in  the  crico-thyroid  membrane.  The  French 
writers,  Sedillot,  Dubrueil,  Chauvel  speak  of  this  method 
as  having  been  entirely  abandoned  because  the  opening 
cannot  be  made  sufficiently  large.  Holmes,  on  the  other 
hand,  considers  it  suitable  in  all  cases  in  which  only  the 
vocal  cords  or  the  tissues  above  them  are  involved,  and 
says  it  is  practiced  in  spasm  of  the  glottis  from  any  cause, 
in  erysipelatous  affections  spreading  down  the  throat,  and 
in  cases  of  foreign  body  lodged  in  or  above  the  glottis. 
If  the  opening  proves  to  be  too  small  it  can  be  enlarged 


360  OPERATIONS   UPON   THE  NECK. 

downward  through  the  cricoid  cartilage  (laryngo-trache- 
otomy).  The  operation  may  be  required  in  cases  of 
urgency  when  no  tube  is  at  hand.  A  pair  of  forceps  or 
scissors,  a  hair-pin,  or  pieces  of  bent  wire  will  suffice  to 
keep  the  wound  open,  and  the  incision  can  be  made  with 
a  penknife. 

Operation. — Dorsal  decubitus,  shoulders  raised  upon  a 
cushion  or  narrow  pillow  so  that  the  head  may  fall  back 
and  keep  the  throat  tense.  The  surgeon,  standing  at  the 
patient's  right  side,  fixes  the  larynx  with  his  left  thumb 
and  middle  finger  placed  on  either  side,  and  the  index 
upon  its  upper  border,  and  makes  a  cutaneous  incision  in 
the  median  line  corresponding  to  the  crico-thyroid  mem- 
brane. He  draws  the  sterno-thyroid  muscles  apart,  lays 
bare  the  membrane,  and  divides  it  transversely  or  verti- 
cally ;  in  the  latter  case  the  incision  should  begin  a  short 
distance  below  the  inferior  border  of  the  thyroid  cartilage, 
so  as  to  avoid  a  small  artery  which  crosses  at  that  point, 
and  extend  to  the  cricoid  cartilage.  (For  the  method  of 
inserting  the  canula,  see  Tracheotomy.) 

Laryngo-tracheotomy. — The  opening  occupies  part  of 
the  crico-thyroid  membrane,  the  cricoid  cartilage,  and  the 
first  two  or  three  rings  of  the  trachea.  The  upper  border 
of  the  isthmus  of  the  thyroid  usually  corresponds  to  the 
second  ring  of  the  trachea;  it  should  not  be  divided.  In 
children  under  six  years  it  commonly  rises  to  the  lower 
border  of  the  cricoid  cartilage. 

Dorsal  decubitus,  with  shoulders  raised,  head  thrown 
back,  and  neck  slightly  stretched.  The  larynx  is  fixed 
as  for  crico-thyroid  laryneotomy,  and  an  incision  made 
through  the  skin  exactly  in  the  median  line  from  the  mid- 
dle of  the  thyroid  cartilage  to  about  one  inch  below  the 
cricoid.  The  muscles  arc  carefully  drawn  apart,  the  isth- 
mus of  the  thyroid  depressed  if  necessary,  after  nicking 
and  tearing  with  blunt  hooks  the  suspensory  fascia  at  its 
upper  border,  the  trachea  steadied  and  drawn  upward  with 
a  sharp  hook  thrust  into  the  upper  part  of  the  crico-thy- 
roid membrane,  and  the  point  of  the  bistoury  entered 
close  below  the  hook  and  made  to  cut  downward  through 


BRONCHOTOMY.  361 

the  cricoid  cartilage  and  one  or  two  of  the  rings  of  the 

trachea.  The  edges  of  the  incision  are  then  held  apart 
and  the  cannla  introduced,  or  the  forceps  if  the  operation 
has  been  undertaken  with  a  view  to  the  removal  of  a  for- 
eign body  or  a  polyp. 

De  Saint  Germain's  Method. — Dorsal  decubitus,  shoul- 
ders raised,  neck  extended.  The  surgeon  feels  for  the1 
cricoid  and  thyroid  cartilages,  and  the  depression  between 
them.  Then,  standing  upon  the  patient's  right  side,  he 
places  his  left  thumb  and  middle  finger  on  either  side  of 
the  larynx,  and  by  pressing  them  in  between  it  and  the 
vertebral  column,  pushes  the  larynx  forward,  makes  tense 
the  skin  covering  it,  and  at  the  same  time  marks  the  sit- 
uation of  the  lower  border  of  the  thyroid  cartilage  with 
the  nail  of  his  left  forefinger. 

The  knife,  a  straight,  sharp-pointed  bistoury,  is  held 
like  a  pen,  its  back  directed  upward,  and  the  middle  finger 
so  placed  upon  its  side  as  to  limit  to  half  an  inch  the 
depth  to  which  the  point  can  penetrate.  It  is  then  en- 
tered with  a  quick  sharp  stab  in  the  median  line  close 
against  the  nail  of  the  left  forefinger  and  made  to  cut 
downward  with  a  sawing  motion  through  the  cricoid  car- 
tilage and  one  or  two  tracheal  rings,  care  being  taken  to 
make  the  incision  in  the  skin  fully  as  long  as  that  in  the 
trachea.  The  wound  is  held  open  with  a  "  dilator,"  and 
the  canula  introduced  between  its  branches  ;  the  pressure 
of  the  latter  is  usually  sufficient  to  arrest  hemorrhage, 
but  ligatures  can  be  easily  applied  if  necessary.  In  only 
one  case  out  of  ninety-seven  did  Saint  Germain  injure 
the  posterior  wall  of  the  trachea,  and  in  only  three  did 
hemorrhage  occur.1 

Tracheotomy. — The  trachea  may  be  opened  at  any 
point  between  the  cricoid  cartilage  and  the  upper  border 
of  the  sternum,  a  distance  averaging  in  the  adult  from  two 
and  one-half  to  three  inches,  in  the  child  under  ten  years 
of  age  from  one  and  one-half  to  two  and  one-half  inches. 
Its  course  is  obliquely  backward  as  well  as  downward,  so 
that  while  its  upper  end  is  almost  subcutaneous  it  be- 
1  Bull,  de  la  Socie'te  de  C'hirurgie,  1877,  pp.  271  and  327. 


362  OPERATIONS   UPON  THE  NECK. 

comes  deeply  placed   before  it  passes  behind  the  sternum. 

It  is  crossed  at  its  upper  end  by  the  isthmus  of  the  thy- 
roid gland,  the    breadth,    thickness,  and    vascularity   of 

which  vary  within  very  wide  limits,  although  its  upper 
border  usually  corresponds  to  the  second  ring  of  the 
trachea.  A  communicating  branch  uniting  the  two  in- 
ferior thyroid  arteries  crosses  just  below  the  lower  border 
of  the  isthmus.  The  lower  portion  is  covered  anteriorly 
by  the  thyroid  veins,  always  greatly  distended  Avhen  the 
respiration  is  obstructed,  and  by  the  thymus  gland  in 
children  under  two  years  of  age,  and  occasionally  in  un- 
healthy older  ones. 

To  the  dangers  depending  upon  the  normal  arrangement 
of  the  parts  are  added  those  of  not  infrequent  anomalies 
in  the  origin  and  course  of  the  arteries  and  veins.  Thus, 
the  left  brachio-cephalic  vein  may  cross  the  trachea  well 
above  the  sternum,  the  left  carotid  may  arise  from  the  in- 
nominate, and  sometimes  a  thyroidea  ima  artery  is  given 
off  from  the  transverse  portion  of  the  arch  of  the  aorta, 
and  ascends  along  the  anterior  surface  of  the  trachea  in 
the  median  line.  Finally,  an  aneurism  of  the  innominate, 
or  of  the  arch  of  the  aorta,  may  rise  in  front  of  this  por- 
tion of  the  trachea. 

Operation. — The  patient  is  placed  upon  his  back  with 
shoulders  raised  and  head  thrown  back.  A  trustworthy 
assistant,  standing  behind  the  head,  holds  it  firmly  in  a 
Straighl  line  with  the  body  ;  others  control  the  patient's 
limbs  if  he  has  not  been  anaesthetized.  The  surgeon, 
standing  at  the  patient's  right  side,  recognizes  with  his 
finger  the  hyoid  bone  and  thyroid  and  cricoid  cartilages, 
and,  marking  with  his  left  forefinger  the  upper  border  of 
tli«'  cricoid  cartilage,  makes  an  incision  downward  from  it 
in  the  median  line  from  one  and  one-half  to  two  inches  in 
length,  according  to  the  size  of  the  patient.  lie  carries 
the  incision  through  the  skin  ami  fascia,  separates  the 
Bterno-hyoid  and  sterno-thyroid  muscles  with  the  handle 
"f  In-  knife,  and  lays  bare  the  isthmus  of  the  thyroid.  If 
any  large  veins   are   encountered,   they  must   be   carefully 

drawn  aside  or  divided  between  two  ligatures,  but  bleed- 


BRONCHOTOMY.  363 

ing  from  smaller  ones  may  be  safely  disregarded,  for,  as 
Trousseau  pointed  out,  it  will  cease  as  soon  as  the  trachea 
is  opened,  and  the  venous  congestion  relieved  by  the  ad- 
mission of  air  to  the  Lungs. 

It  is  well  to  have  one  or  two  assistants  hold  the  sides 
of  the  incision  apart  during-  the  disseetion,  if  they  can  be 
depended  upon  to  do  so  without  disturbing  the  relation- of 
the  parts  by  drawing  too  forcibly  toward  one  side  or  the 
other. 

The  isthmus  of  the  thyroid  is  next  drawn  upward  with 
a  blunt  hook,  and  three  or  four  ring's  of  the  trachea  ex- 
posed below  it,  and  divided  from  below  upward.  If  for 
any  reason  it  is  desirable  to  make  the  incision  higher  up, 
or  if  the  isthmus  is  unusually  broad,  it  may  be  divided 
between  two  ligatures,  in  which  case  the  incision  of  the 
trachea  should  be  made  from  the  lower  border  of  the  cri- 
coid cartilage  downward. 

The  incision  in  the  trachea  should  always  be  free  enough 
to  admit  the  canula  readily,  and  should  be  made  by  a 
quick  thrust  with  a  sharp-pointed  knife,  which  must  be 
prevented  from  penetrating  too  deeply  at  first,  by  holding- 
it  close  to  its  point.  After  the  puncture  has  been  thus 
made,  it  is  enlarged  by  gentle  sawing  movements  of  the 
knife,  or  with  scissors. 

The  knife  is  retained  in  the  trachea  as  a  guide,  until  the 
dilator  has  been  introduced.  The  best  dilator  is  the  three- 
bladed  one  ;  it  is  introduced  closed,  its  blades  then  ex- 
panded, and  the  permanent  canula  passed  in  between  them. 
The  canula  should  be  curved,  double  to  facilitate  cleaning, 
and  provided  with  an  opening  on  its  convexity  through 
which  the  expired  air  can  pass  to  the  larynx. 

Some  surgeons  steady  the  trachea  by  drawing  it  toward 
the  chin  with  a  tenaculum  introduced  at  the  lower  edge  of 
the  cricoid  cartilage.  Gurdon  Buck  used  for  this  pur- 
pose a  rather  narrow  lance-shaped  knife,  bent  at  a  right 
angle  on  the  Hat,  and  also  grooved  on  the  back  for  use  as 
a  director. 

G-alvano-  or  Thermo-cautery. — The  danger  of  hemor- 
rhage, especially  in  the  adult,  has  led  many  surgeons  to 


•')<'»4  OPERATIONS   UPON   THE  NECK. 

use  the  galvano-  or  thermo-cautery.  Its  hemostatic  ad- 
vantages, however,  are  offset  by  a  large  eschar  which  it 
causes,  and  the  possible  necrosis  of  the  tracheal  cartilages." 
The  cautery  should  be  used  only  to  divide  the  soft  parts, 
the  trachea  should  be  opened  with  the  knife. 

LARYNGECTOMY.2 

Complete. — A  preliminary  tracheotomy  is  necessary. 
A  pad  is  placed  under  the  shoulders  and  the  head  thrown 
well  back.  The  incision  is  in  the  median  line,  and  ex- 
tends from  the  thyro-hyoid  space  to  the  second  or  third 
tracheal  ring.  A  transverse  incision  joins  this  at  the  up- 
per end  and  passes  outward  parallel  to  the  hyoid  bone  as 
far  as  each  sterno-mastoid  muscle.  The  skin,  fascia,  and 
platysma  are  drawn  aside  and  the  superior  thyroid  arteries 
secured  at  the  posterior  margin  of  the  thyro-hyoid  muscle 
beneath  the  sterno-hyoid  close  to  the  upper  border  of  the 
thyroid  cartilage.  Next  the  inferior  thyroid  arteries  are 
ligated  below,  beneath  the  posterior  edge  of  the  sterno- 
thyroid muscles. 

By  means  of  a  periosteal  elevator  or  blunt-pointed  scis- 
sors entered  beneath  the  fascia  in  the  middle  line  the  crico- 
thyroid, sterno-thyroid,  and  thyro-hyoid  muscles  on  each 
side  are  detached  and  retracted  with  the  other  soft  parts. 
The  thyroid  cartilage  is  drawn  first  to  one  side  and  then 
to  the  other,  and  the  inferior  constrictor  muscle  separated. 
All  cutting  should  be  done  with  the  blunt-pointed  scis- 
sors kept  close  to  the  cartilages.  The  superior  laryngeal 
nerves  and  the  thyro-hyoid  membranes  and  ligaments  are 
divided,  the  epiglottis  drawn  out  and  its  extra-laryngeal 
attachments  cut.  The  larynx  is  next  pulled  forward  and 
separated  from  any  remaining  connection  with  the  phar- 
ynx or  oesophagus  to  a  point  just  below  the  cricoid  carti- 
lage. Great  care  is  necessary  to  avoid  opening  the  oesoph- 
agi i.-.  The  trachea  is  secured  from  slipping  down  by  a 
temporary  suture  on  each  side  and  is  cut  across  below  the 

1  See  the  discussion  in  the  Societe"  <lc  Chirurgie,  May  '.'  to  .lime  13, 

1-77. 

'Hahn,  Volkniaun's  SaiimiluiiK,  18S">,  No.  2G0. 


LA  R  YNGECTOMY.  365 

cricoid  cartilage.  The  divided  end  is  secured  at  the  sur- 
face in  the  wound  with  interrupted  silk  sutures  and  the 
mucous  membrane  sutured  to  the  margins  of  the  skin 
incision. 

When  there  is  doubt  about  the  extent  of  the  laryngeal 
disease,  the  thyroid  cartilage  should  be  split  in  the  middle 
line  as  soon  as  it  has  been  exposed.  This  is  done  by 
steadying  the  larynx  and  cutting  from  before  backward 
with  the  knife  or  from  below  upward  with  blunt-pointed 
scissors  entered  through  the  crico-thyroid  membrane.  Ii' 
then  on  inspection  it  is  found  that  the  whole  larynx  must 
be  sacrificed  the  operation  is  proceeded  with  as  already 
described.  It  is  usually  recommended  to  remove  the 
cricoid  cartilage  in  all  cases  of  total  extirpation,  as  it  is 
of  no  functional  value  and  its  retention  interferes  with 
the  act  of  swallowing. 

Partial. — An  incision  is  made  in  the  median  line  as  in 
total  laryngectomy,  and  from  its  upper  end  a  second  is 
made  parallel  to  and  just  below  the  hyoid  bone  on  the 
affected  side  as  far  as  the  sterno-mastoid  muscle.  This 
involves  the  skin,  fascia,  and  platysma.  The  thyroid  car- 
tilage is  then  divided  vertically  exactly  in  the  median  line 
with  the  knife  or  scissors. 

After  separation  of  the  ala?  Mr.  Butlin  '  advises,  if  the 
disease  is  of  limited  extent,  that  it  be  cut  away,  with  a 
wide  margin  of  healthy  tissue,  meaning  that  it  be  scooped 
out  of  the  concavity  of  the  ala  with  the  surrounding  mu- 
cous membrane.  The  ala  of  the  thyroid  is  then  restored 
to  its  place.  Mr.  Butlin  claims  that  cancer  does  not  infil- 
trate the  cartilage,  and  therefore  it  is  only  necessary  to 
scrape  and  cauterize  the  part  adjacent  to  the  disease. 

If  one-half  of  the  thyroid  cartilage  must  be  removed, 
the  sterno-thyroid  muscle  is  cut  at  its  upper  end  and  laid 
back.  The  thyro-hyoid,  sterno-thyroid,  and  crico-thyroid 
muscles  are  carefully  detached  with  the  elevator  or  blunt- 
pointed  scissors.  The  thyroid  and  crico-thyroid  mem- 
branes and  superior  laryngeal  nerve  are  cut  close  to  the 
cartilage,  and  vessels  are  secured  as  they  are  divided. 
■Op.  Surg.  Malig.  Disease. 


366  OPERATIONS   UPON  THE  NECK 

The  superior  corau  of  the  thyroid  cartilage  is  cut  through 
at  its  base.  The  whole  or  part  of  the  epiglottis  is  left 
and  the  aryteno-epiglottic  fold  of  mucous  membrane 
spared  as  much  as  possible.  The  pharyngeal  Avail  must 
be  freed  with  great  care.  The  inferior  cornu  is  divided, 
any  remaining  attachments  severed  with  short  snips  of 
the  scissors  and  the  ala  removed. 

The  parts  are  then  sutured  in  their  proper  positions  as 
nearly  as  possible  after  placing  over  the  denuded  surface 
all  the  mucous  membrane  obtainable. 

PHARYNGOTOMY. 

This  is  an  operation  required  for  the  removal  of  foreign 
bodies  or  diseased  tissue  from  the  pharynx  or  immediately 
adjoining  parts  which  are  not  accessible  through  the 
mouth.  Langenbeck's  (page  354),  or  the  Crespi-Bas- 
tianelli  methods  (page  354),  for  reaching  the  base  of  the 
tongue  are  also  useful  for  exposing  the  tonsil  and  posterior 
pharyngeal  wall.  Aplavin's  sub-hyoid  pharyngotomy 
(page  358)  gives  a  somewhat  limited  view  of  the  parts 
around  the  entrance  to  the  larynx. 

Gaps  left  after  excision  of  portions  of  the  wall  of  the 
pharynx  must  be  left  to  granulate  ;  if  the  epiglottis  has 
been  disturbed  its  attachments  must  as  far  as  possible  be 
replaced  and  sutured  in  their  proper  position. 

Von   Langenbeck's  Method.1 — After  a  preliminary 

tracheotomy  the  head  is  extended  and  chill  turned  to  the 
side  opposite  to  the  one  to  be  operated  upon.  The  incision 
extends  from  the  middle  of  the  lower  border  of  the  body 
of  the  inferior  maxilla  downward  across  the  greater  corn  11 
of  the  hyoid  bone  along  the  posterior  border  of  the  thyro- 
hyoid muscle  to  the  cricoid  cartilage  or  a  little  further. 
After  division  of  the  superficial  fascia,  platysma,  and 
omohyoid,  the  lingual,  and  superior  thyroid  arteries  and 
facial  vein  arc  cut  and  secured.  Both  branches  of  the 
superior  laryngeal  nerve  are  divided.  After  freeing  the 
attachments  of  the  digastric  ami  stylo-hyoid  from  the 
hvoid  bone  the  pharynx  is  laid  open  through  the  whole 
'Archiv  f.  klin.  Chir.,  1879,  Bd.  24,  p.  825. 


P1IARYNG0T0MY.  367 

length  of  the  wound.  The  thyroid  cartilage  can  be  turned 
on  its  long  axis  so  that  its  posterior  surface  is  visible  in 
the  wound  and  the  pharynx  is  accessible  as  high  as  the 
soft  palate. 

Another  method  of  the  same  surgeon's  is  as  follows: 
A  U -"Shaped  flap  of  skin  and  subcutaneous  tissue  is  made, 
the  base  of  which  is  above  and  corresponds  in  width  to 
the  length  of  the  zygoma.  Its  sides  and  bottom  follow 
the  anterior  border  of  the  masseter  muscle,  the  posterior 
border  of  the  ramus,  and  the  intervening  portion  of  the 
lower  border  of  the  jaw,  respectively.  The  inferior 
maxilla  is  sawn  through  in  front  of  the  insertion  of  the 
masseter,  and  the  ramus  dislocated  by  turning  it  outward 
and  upward. 

Butlin  '  describes  an  operation  by  Czerny,  which  is 
virtually  the  same  as  Von  Langenbeck's  for  excision  of 
the  tongue.  The  incision  extends  from  the  angle  of  the 
mouth  to  the  extremity  of  the  hyoid  bone,  and  the  jaw  is 
sawn  through  obliquely  from  above  and  without  down- 
ward and  inward  between  the  second  and  third  molar  teeth. 

MIKULICZ'S  Method.2 — After  a  preliminary  trache- 
otomy and  plugging  of  the  fauces  or  larynx  an  incision  is 
made  from  the  tip  of  the  mastoid  process  to  the  level  of 
the  greater  cornu  of  the  hyoid  bone.  The  periosteum  and 
overlying  parts  are  raised  from  the  outer  and  inner  surface 
of  the  ascending  ramus  of  the  inferior  maxilla,  special  care 
being  taken  to  avoid  injury  if  possible  to  the  facial  nerve, 
parotid  gland,  and  external  carotid  artery.  The  ascend- 
ing ramus  is  then  divided  horizontally  just  above  the 
angle,  and  partially  or  entirely  excised  after  severing  the 
tendon  of  the  temporal  muscle. 

After  drawing  aside  the  both-  of  the  jaw,  together  with 
the  masseter,  internal  pterygoid,  digastric,  and  stylo-hvoid 
muscles,  the  region  of  the  tonsil  is  exposed.  The  lateral 
wall  of  the  pharynx  is  then  incised  and  access  thus  ob- 
tained  to   the   palate,    base   of  the   tongue,   and    posterior 

'Operat.  Surg.  Malig.  Disease. 

2Deut.  med.  Wochens.,  1886,  Vol,  XII.,  y.  157, 


368  OPERATIONS   UPON  THE  NECK. 

pharyngeal  wall  as  far  up  as  the  naso-pharynx.  If  the 
digastric  muscle  and  hypoglossal  nerve  are  divided  the 
entrance  of  the  larynx  can  be  reached.  The  disease  is  re- 
moved with  the  knife  or  scissors,  the  mucous  membrane 
drawn  together,  and  the  wound  closed  and  drained. 

Ciieever's  Method. — An  oblique  incision  is  made 
from  the  lobule  of  the  ear  downward  along  the  anterior 
border  of  the  sterno-mastoid  muscle  to  the  hyoid  bone  or 
below  it.  A  second  is  carried  forward  from  this  along  the 
lower  border  of  the  body  of  the  inferior  maxilla.  The 
tissues  are  divided  layer  by  layer,  and  the  vessels  secured. 
Enlarged  lymphatic  glands  are  removed  as  they  are  en- 
countered. The  branches  of  the  facial  nerve  are  recog- 
nized and  drawn  to  one  side.  The  hypoglossal  nerve  lies 
behind  and  in  the  lower  end  of  the  incision,  and  is  drawn 
outward  and  backward  with  the  great  vessels.  The  glosso- 
pharyngeal nerve  lies  anteriorly. 

The  fascia  investing  the  posterior  part  of  the  submax- 
illary gland  is  slit  up,  and  the  facial  artery  tied.  The 
digastric  and  stylo-hyoid  muscles  are  divided,  the  sub- 
maxillary gland  drawn  forward  and  the  parotid  up,  and 
the  wall  of  the  pharynx  thus  exposed. 

The  tonsil  and  the  surrounding  mucous  membrane  are 
then  removed.  Bird  '  dispensed  with  the  incision  along 
the  lower  border  of  the  jaw,  but  slit  the  cheek  from  the 
angle  of  the  mouth  to  the  angle  of  the  jaw  and  removed 
the  tonsil,  using  one  finger  in  the  mouth  for  a  guide. 

(ESOPHAGOTOMY. 
The  oesophagus  begins  in  front  of  the  sixth  cervical 
vertebra  in  the  median  line,  or  just  behind  the  cricoid 
cartilage;  at  first  it  inclines  slightly  toward  the  left,  then 
returns  to  the  median  line  as  it  passes  behind  the  sternum, 
inclines  to  the  right  at  the  arch  of  the  aorta,  and  again  to 
tin'  lift  as  it  approaches  the  diaphragm.  The  left  recur- 
rent laryngeal  nerve  lie-  between  its  cervical  portion  and 
the  trachea,  the  right  recurrent  nerve  lies  upon  its  outer 
side.  It  i-  covered  anteriorly  by  the  trachea  and  left 
'Clin.  Soc.  Trans.,  Vol.  XVI.,  i).  9. 


'  KSOPHA  GOTOM  Y.  369 

lobe  of  the  thyroid  gland,  and  crossed  by  the  left  inferior 
thyroid  artery  and  vein.     The  guide  to  it  is  the  trachea. 

Internal  (Esophagotomy. — Dr.  Sand-  employed  an  in- 
strument constructed  <>n  the  principle  of  the  Otis  urethra- 
tome.  It  consisted  of  a  long  shank  carrying  a  bull)  with 
a  sheathed  knife  which  could  be  made  to  project  not  more 
than  an  eighth  of  an  inch  from  the  surface  of  the  envelop- 
ing bulb  by  turning  a  -crew  in  the  handle.  Other  sur- 
geons have  used  similar  instruments,  but  on  account  of 
the  danger  of  perforating  the  (esophagus  operations  per- 
formed by  the  knife  from  the  interior  of  the  organ  have 
been  practically  abandoned  in  favor  of  Abbe's  "string- 
saw  *'  method,1  which  is  one  of  combined  dilatation  and 
division. 

It  is  used  for  cicatricial  strictures  which  are  undilat- 
able  and  generally  impermeable  to  any  instrument  passed 
from  above,  but  which  reason  and  experience  have  shown 
may  be  passed  from  below,  where  tbe  tube  is  contracted 
and  funnel-shaped,  while  above  it  is  dilated  and  pouched. 

Gastrostomy  is  first  performed,  the  opening  into  the 
stomach  being  made  large  enough  to  admit  two  fingers 
with  the  exploring  instrument  to  the  cardiac  orifice  of  the 
stomach.  Into  the  latter  a  bougie  carrying  a  long  silk 
cord  is  passed  and  brought  out  at  the  mouth  ;  the  other 
end  of  the  cord  remains  in  the  abdominal  wound.  Then 
the  stricture  is  made  tense  by  engaging  a  conical  bougie 
in  it,  and  the  string,  held  well  back  at  either  end  in  the 
pharynx  and  stomach,  is  drawn  tight  and  sawed  up  and 
down  a  few  times.  After  this  bougies  are  passed  up  to 
the  largest  size  or  till  firm  resistance  is  encountered.  In 
Abbe's  first  ease  external  (esophagotomy  was  performed, 
and  after  division  and  dilatation  of  the  stricture  as  above 
described  a  rubber  tube  was  drawn  up  from  tbe  stomach 
and  wedged  into  the  contraction  for  twenty-four  hours, 
thus  maintaining  the  dilatation. 

When  there  is  no  further  trouble  in  the  passage  of  bou- 
gies from  above,  the  gastrostomy  wound  is  closed,  but  in- 
struments must  subsequently  be  introduced  through   the 

'New  York  Medical  Record.  February  25,  1893. 

•J-i 


370  OPERATIONS   UPON  THE  NECK 

stricture  at  regular  intervals  till  the  danger  of  recontrac- 

tion  is  <»vcr.' 

External  (Esophagotomy. — -The  operation  of  external 
cesophagotoray  may  be  required  for  the  relief  of  stricture, 
or  the  removal  of  a  foreign  body.  In  the  former  case,  it 
may  be  performed  above  or  at  the  level  of  the  stricture 
for  the  purpose  of  dividing  or  dilating  it,  or  below  the 
stricture  so  as  to  allow  the  introduction  of  food  into  the 
.stomach.  The  left  side  of  the  oesophagus  is  more  accessi- 
ble in  the  neck  than  the  right,  and  the  incision  may  lie 
made  in  the  median  line  or  parallel  to  the  inner  border  of 
tin  Bterno-cleido-mastoid  muscle.  As  the  walls  of  the 
oesophagus  are  flaccid,  a  guide  should  be  used  if  it  is  pos- 
sible  to  introduce  one.  A  sufficiently  convenient  one  is  a 
pair  of  long  curved  forceps,  or  even  a  urethral  sound, 
introduced  through  the  mouth  ;  the  point  can  be  made  to 
press  the  wall  toward  the  approaching  knife. 

Lateral  Incision. — Dorsal  decubitus,  head  extended,  face 
turned  slightly  to  the  right.  The  surgeon,  standing  at 
the  patient's  left,  makes  an  incision  through  the  skin, 
subcutaneous  cellular  tissue,  and  the  platysma  a  little  on 
the  inner  side  of  the  inner  border  of  the  sterno-clcido- 
mastoid  from  a  point  one  inch  above  the  sternum  to  the 
level  of  the  upper  border  of  the  thyroid  cartilage.  If  the 
external  or  anterior  jugular  is  encountered,  it  must  be 
drawn  aside  or  divided  between  two  ligatures.  The  fascia 
is  then  divided,  the  omo-hyoid  muscle  drawn  aside,  and 
then  the  side  of  the  thyroid  gland  followed  downward. 
The  Bterno-cleido-mastoid  and  the  great  vessels  arc  drawn 
outward  with  a  blunt  hook,  the  trachea  and  thyroid  gland 
to  the  right,  and  then  the  surgeon,  working  with  blunt 
instruments,  separates  the  tissues  at  the  bottom  of  the 
wound  and  exposes  the  oesophagus,  which  can  be  recognized 
bv  it-  flattened  appearance  and  thick  wall.  If  more  room 
is  needed,  the  -ternal  head  of  the  Bterno-cleido-mastoid 
iiui-t  be  divided.     Then  a   guide   is   introduced   through 

'A  resume*  of  this  operation  with  a  report  of  cases  and  description  <>f 
ili.-  various  expedients  which  may  !><•  necessary  will  !><•  found  in  the 
Annals  of  Surgery,  March,  1895,  p,  '_'•">■;.     Dr.  Woolsey. 


OPERATIONS  ON  THE  THYROID  GLAND.        371 

the  mouth,  and  the  wall  of  the  oesophagus  pressed  up  at 
the  bottom  of  the  wound.  The  surgeon,  having  satisfied 
himself  that  the  recurrent  laryngeal  nerve  and  inferior 
thyroid  artery  are  out  of  the  way,  punctures  the  oesophagus 
by  picking  it  ii|>  with  two   hooks   Or   toothed    forceps   and 

cutting    between  them,  and   enlarges    the  opening   with 

scissors  or  a  blunt-pointed  bistoury. 

At  the  close  of  the  operation  the  wound  in  the  oesopha- 
gus is  closed  with  catgut,  that  in  the  overlying-  parts  be- 
ing left  open  and  packed  ;  the  patient  is  fed  by  the  rectum 
or  with  the  stomach  tube  for  several  days  ;  or  a  tube, 
through  which  the  patient  should  be  fed  for  several  days, 
is  passed  through  the  wound  well  into  the  (esophagus  and 
carefully  packed  about.  The  capital  point  is  to  insure 
drainage  of  the  wound  which  will  certainly  be  infected 
from  the  oesophagus  during  the  operation  or  shortly  there- 
after. 

If  a  permanent  fistula  is  desired  (below  a  malignant 
contraction,  for  instance)  the  margins  of  the  cutaneous  and 
(esophageal  wounds  are  united  with  sutures. 


THE  OPERATIONS  ON  THE  THYROID  GLAND. 

Anatomy. — Normally  the  isthmus  is  about  half  an  inch 
broad  and  covers  the  second  and  third  tracheal  rings, 
while  the  lateral  lobes  extend  upward  and  backward  to 
the  lower  end  of  the  pharynx,  lying  on  each  side  of  the 
larynx,  and  downward,  in  contact  with  the  upper  end  of 
the  oesophagus.  The  thyroid  is  enveloped  by  the  fascia 
of  the  neck  and  possesses  a  capsule  enclosing  the  gland 
tissue  proper.  When  enlarged  the  organ  is  covered  with 
a  plexus  of  veins  ;  the  most  constant  and  important  of 
these  are  represented  diagrammatically  in  Figs.  185  and 
186  and  need  no  further  explanation.  The  gland  is  over- 
lapped by  the  sterno-mastoid  and  has  resting  on  its  sur- 
face the  sterno-hyoid,  omo-hyoid,  and  sterno-thyroid  mus- 
cles in  this  order  from  before  backward.  One  or  more 
accessory  thyroids  may  be  found  above  or  below  the  lateral 
lobes,  and  it  should  be  noted   that  the  latter  mav,  when 


372 


OPERATIONS   UPON  THE  NECK. 


enlarged,  extend  downward  behind  the  sternum.  The 
lateral  lobes  overlap  the  great  vessels  of  the  neck  with 
their  accompanying  nerves,  and  are  in  contact  at  their 
lower  posterior  portions  with  the  inferior  thyroid  artery, 
the  recurrent  laryngeal  nerve,  and  middle  cervical  gan- 
glion of  the  sympathetic.  The  artery  passes  horizontally 
inward   from   the  inner  border  of   the    scalenus  anticns 


Fig.  185. 


a.  Chin.  b.  Sterno-mastoid.  c.  Omo-byoid.  </.  Sternohyoid,  e.  Sterno-thyroid. 
<•  Vena  jugularis  ext.  .'/.  Vena  jugularis  obliqua.  h.  Vena  jugularis  ant.  f.  Vena 
jugularis  Inf.  comniunicans.  j.  vena  jugularis  sup.  communicans.  1,2,3.  Double 
ligatures  applied  to  the  above-menti I  veins  in  the  line  of  the  incMon.  iKocher.  ) 

muscle  about  half  an  inch  below  the  carotid  tubercle, 
then  forward  on  the  oesophagus  and  trachea,  and  divides 
into  an  ascending  and  descending  branch.  At  its  point 
of  bifurcation  it  is  crossed  (in  front  or  behind)  by  the 
recurrent  laryngeal  nerve,  and  at  the  inner  border  of  the 
scalenus  anticus  the  middle  cervical  ganglion  lies  directly 
upon  it.  Great  care  is  necessary  in  securing  the  artery 
in  order  to  avoid  injury  to  these  structures  ;    paralysis  of 


OPERATIONS  OH    THE  THYROID  QLAND. 


373 


one  recurrent  nerve  produces  paralysis  of  the  correspond- 
ing vocal  cord,  of  both  nerves,  severe  dyspnoea,  which 
may  end  fatally  if  not  relieved  by  tracheotomy  ;  injury 
to  the  sympathetic  at  this  point  destroys  the  three  cardiac 
branches  which  are  given  off'  here  or  jnst  below.  The 
operations  which  arc  considered  justifiable  are  removal  of 
a  portion  of  the  gland,  enucleation  of  the  same,  and  liga- 

Fig.  186. 


«.  Sup.  thyroid  artery,  h.  Sup.  thyroid  rein.  e.  Carotid  artery,  d.  Internal 
jugular  vein.  e.  Accessory  sup.  thyroid  vein.  /.  Sup.  communicating  thyroid  vein. 
<i.  Inf.  communicating  thyroid  vein.  h.  Accessory  inferior  thyroid  vein.  i.  In- 
ferior thyroid  vein.  k.  Thyroidea  ima  veins.  /.  Left  innominate  vein.  The 
numerals  indicate  the  points  where  the  ahove-mentioned  veins  are  ligated. 


tion  of  the  afferent  arteries,  the  latter  being  applicable  to 
rapidly  growing,  vascular  (not  fibrous  or  cystic)  goitres 
in  young  subjects. 

Ligation  of  the  Arteries. — On  account  of  the  danger  of 
a  general  atrophy  only  the  vessels  in  immediate  connection 
with  the  enlarged  part  should  be  secured,  the  superior  and 
inferior  thyroid  arteries  of  one  side,  for  example.     Then 


374  OPERATIONS   UPON  THE  NECK 

if  this  Fail  the  others,  starting  with  the  nearest,  may  be 
successfully  tied.  The  superior  arteries  are  exposed  and 
ligated  as  described  on  page  II,  and  the  inferior  prefer- 
ably by  Drobeck's  method  (p.  42),  especially  if  the  gland 
is  much  hypertrophied. 

Enucleation  of  a  Portion  of  the  Gland. — Some  eases  of 
sharply  defined  tumor  of  the  thyroid,  such  as  cystic  goitre, 
need  only  a  longitudinal  incision  over  the  most  prominent 
part  of  the  growth  with  division  of  the  tissues  layer  by 
layer,  and  ligation  of  the  vessels  encountered  till  the  gland 
is  reached.  The  capsule  and  layer  of  gland  tissue  (some- 
times no  thicker  than  a  sheet  of  paper)  overlying  the  tumor 
is  then  divided  and  the  latter  shelled  out. 

Removal  of  a  Portion  of  the  Thyroid  Gland  (Kocher). — 
The  incision  extends  in  the  median  line  from  the  sternal 
notch  to  the  upper  limit  of  the  tumor.  From  this  point 
it  runs  obliquely  toward  the  angle  of  the  jaw  on  the  side 
from  which  the  affected  half  of  the  gland  is  to  be  removed 
(Fig.  185).  If  the  entire  gland  is  to  be  removed,  a  pro- 
cedure which  must  be  seldom  justifiable,  the  oblique  in- 
cision is  made  on  both  sides,  thus  giving  the  skin-cut  the 
form  of  a  Y-  The  integument,  fascia,  and  platysma  are 
divided  and  the  flaps  turned  back.  The  sterno-hyoid, 
sterno-thyroid,  and  omo-hyoid  muscles,  which  may  he 
much  thinned  and  stretched  out  over  the  surface  of  the 
tumor,  will  have  to  be  cut.  If  adherent  to  its  surface 
they  should  be  lifted  and  pushed  aside  with  blunt-pointed 
scissors  or  a  periosteal  elevator.  .  A  plexus  of  large  thin- 
walled  veins,  which  tear  very  easily,  will  be  found  lying 
close  over  the  surface  of  the  enlarged  gland,  and  should 
be  divided  separately  between  double  ligatures.  The  an- 
terior surface  of  (he  growth  is  thus  cleared  and  the  lateral 
aspeci  approached.  The  sterno-mastoid  muscle  is  retracted 
and  the  common  carotid  artery  and  internal  jugular  vein 
are  carefully  freed  with  a  blunt  instrument.  The  superior 
thyroid  artery  is  secured  at  the  upper  extremity  of  the 
tumor  and.  together  with  the  accompanying  veins,  divided 
between  a  double  ligature.  It  is  generally  recommended 
to  cut  the  branches  of  the  inferior  thyroid  artery  close  to 


OPERATIONS  <>x   THE  THYROID   CLAM).        375 

the  tumor  and  secure  each  as  it  is  divided,  as  in  this  way 
there  is  less  danger  of  injuring  the  recurrent  laryngeal 
nerve  which  is  in  close  relationship  with  it  on  each  side. 
Furthermore,  on  the  left  side  the  main  portion  of  the 
artery  lies  in  contact  with  the  (esophagus  ;  and  the  thoracic 
duct,  which  is  at  first  posterior  to  the  artery,  arches  over 
it  to  reach  the  left  subclavian  vein.  Or  the  trunk  of  the 
interior  thyroid  artery  may  be  tied,  preferably  by  Dro- 
beck's  method,  as  described  on  page  A'2. 

The  dissection  is  continued  close  to  the  capsule,  which 
must  nowhere  be  opened  ;  every  vessel,  as  it  is  en- 
countered, is  tied  and  cut  separately  after  careful  inspec- 
tion, and  the  lateral  surface  of  the  tumor  cleared.  Its 
margin  is  lifted  up,  starting  at  one  side  above  and  work- 
ing downward  and  inward  ;  the  trachea  and  (esophagus 
are  separated  with  special  regard  for  the  recurrent  laryn- 
geal nerve  which  lies  in  the  groove  between  these  struc- 
tures. Thus  the  dissection  is  carried  from  the  side  as  far 
as  the  middle  line  posteriorly.  The  gland  is  then  drawn 
forward  and  upward.  The  vessels  entering  it  from  below 
are  secured  and  divided  and  the  gland  removed. 

Removal  of  the  Isthmus.1 — A  median  longitudinal  in- 
cision is  employed.  It  extends  from  the  upper  to  the 
lower  border  of  the  enlarged  isthmus  and  involves  the  in- 
tegument and  superficial  fascia.  The  anterior  jugular 
vein,  if  encountered,  is  secured  and  cut  between  a  double 
ligature.  The  interval  between  the  sterno-hyoid  and 
sterno-thyroid  muscles  is  opened  up  and  the  muscles 
drawn  aside.  The  isthmus  is  exposed  after  ligating  sepa- 
rately each  one  of  the  enlarged  veins  which  may  be  en- 
countered in  front  of  it.  It  is  then  freed  on  its  upper 
and  lower  border  and  posteriorly  with  a  blunt  instrument. 
The  capsule  itself  must  not  be  opened  and  every  vessel 
should  be  tied  as  it  is  encountered. 

An  aneurism-needle  threaded  with  a  double  ligature  is 
then  made  to  perforate  the  isthmus  on  each  side  from  be- 
hind forward  at  its  junction  with  the  lateral  lobes,  the 
ligatures  are  tied,  and  the  intermediate  segment  of  the 
isthmus  removed. 

'Jones  :    Lancet,  1875,  Vol.  I.,  p.  120. 


CHAPTER  V. 
OPERATIONS  UPON  THE  THORAX. 

AMPUTATION  OF  THE  BREAST. 

The  patient  is  placed  upon  her  back,  inclined  some- 
what toward  the  opposite  side,  and  the  arm  abducted  so 
as  to  make  the  skin  and  pectoral  muscle  tense.  Two 
curved  incisions  are  made,  enclosing  an  elliptical  strip  of 
skin  of  greater  or  less  breadth  according  to  the  extent  of 
its  implication  in  the  disease,  the  long  axis  of  which  is  di- 
rected toward  the  axilla ;  that  is,  upward  and  backward. 
The  upper  and  lower  skin  flaps  are  then  dissected  off  the 
anterior  surface  of  the  gland,  its  upper  border  turned,  ex- 
posing the  pectoral  muscle,  and  the  loose  cellular  tissue 
between  it  and  the  muscle  rapidly  divided  with  a  few 
strokes  of  the  knife,  beginning  at  the  upper  border  of  the 
inner  angle,  while  the  gland  is  drawn  away  from  the 
chest  wall,  and  the  removal  completed  along  the  lower  in- 
cision, or  at  the  axillary  angle  of  the  wound. 

Bleeding  during  the  operation  must  be  controlled  by 
clamps  upon  the  bleeding  points,  and  the  vessels  secured 
afterward  with  ligatures  or  by  torsion.  The  incision  is 
then  prolonged  just  posterior  to  the  anterior  fold  of  the 
axilla,  up  to  the  arm.  The  axillary  vein  is  exposed  at 
the  outer  end  of  the  incision,  where  it  is  most  superficial 
and  is  kept  constantly  in  sight  as  the  dissection  progresses. 
The  axillary  glands  whether  perceptibly  enlarged  or  not, 
together  with  the  surrounding  fat  and  connective  tissue, 
are  removed  en  masse. 

II ai.stkd's  Operation.1 — Halsted's  method,  in  which 
the  greater  pari   of  the  pcetoralis  major  is  systematically 
1  Annuls  of  Surgery,  1894. 
376 


PARACENTESIS  OF  THE  THORAX.  -''.77 

removed  in  all  cases  of  carcinoma,  is  now  generally  em- 
ployed, with  or  without  modifications  of  the  skin  incision. 
The  main  incision  broadly  encircles  the  nipple  and  in- 
volved skin  and  is  prolonged  to  the  arm  along  the  front 
of  the  anterior  fold  of  the  axilla  ;  a  second  incision  passes 
from  the  outer  part  of  the  first  toward  the  middle  of  the 
clavicle.  The  skin  flaps  are  dissected  back,  and  all  the 
narrower  part  of  the  pectoralis,  except,  perhaps,  the  fibers 
coming  from  the  clavicle,  is  divided  close  to  the  humerus. 
The  muscle,  with  the  overlying  gland,  is  then  cut  away 
from  the  chest,  the  pectoralis  minor  divided  if  necessary, 
and  then  a  very  clean  dissection  made  of  the  axilla,  re- 
moving all  the  fat  and  lymphatic  glands  and  the  bundle 
of  tissue  connecting  them  with  the  mamma  and  pectoralis 
major. 

PARACENTESIS  OF  THE  THORAX. 

Each  of  the  lower  posterior  intercostal  arteries  enters  its 
corresponding  intercostal  space  near  the  spinal  column, 
and  passes  obliquely  from  below  upward  across  the  space 
to  shelter  itself  in  a  groove  on  the  inner  side  of  the  lower 
border  of  the  upper  rib.  It  occupies  this  groove  until  it 
reaches  the  anterior  third  of  the  space,  when  it  leaves  it 
to  anastomose  with  the  branches  of  the  anterior  intercostal 
artery  coming  from  the  internal  mammary.  At  this  point, 
however,  it  is  so  small  that  its  division  is  not  of  much 
consequence.  The  only  part  of  its  course  where  its  injury 
is  to  be  feared  is  in  the  posterior  third  of  the  intercostal 
space  before  it  has  passed  behind  the  lip  of  the  rib.  Con- 
sequently, if  an  opening  is  to  be  made  into  the  pleural 
cavity,  cither  with  a  knife  or  trocar,  a  point  in  the  middle 
third  of  one  of  the  intercostal  spaces  should  be  selected, 
preferably  the  seventh,  certainly  not  higher  than  the  sixth, 
nor  lower  than  the  eighth  on  the  right  side,  the  ninth  on 
the  left. 

After  determining  the  position  of  the  intercostal  space, 
often  a  matter  of  considerable  difficulty  in  consequence  of 
the  infiltration  of  the  parts,  make  an  incision  parallel  to 
it,  one  or  one  and  one-half  inches  in  length.      Divide  the 


378  OPERATIONS   UPON  THE  THORAX. 

tissues  layer  by  layer,  until  the  rib  can  be  distinctly  felt 
with  the  finger  introduced  into  the  wound.  Place  the 
end  of  the  finger  upon  the  upper  border  of  the  lower  rib, 
and,  keeping  the  knife  close  to  the  border,  divide  the 
muscles  and  pleura. 

If  a  trocar  or  the  aspirator  is  used,  it  must  be  thrust  in 
with  a  sharp  push  so  as  certainly  to  penetrate  the  pleura, 
which  is  often  thick  and  tough.  The  outer  end  of  the 
canula  is  then  connected  with  a  Dieulafoy  or  Potain 
aspirator  by  means  of  a  rubber  tube  and  the  effusion 
drawn  off.  A  better  method  is  to  make  use  of  the  prin- 
ciple of  the  siphon.  After  filling  the  canula  and  tube, 
previously  rendered  aseptic  and  filled  with  sterilized  water, 
the  end  of  the  tube  is  occluded  and  the  canula  thrust  into 
the  pleural  cavity.  The  tube  is  then  conducted  beneath 
the  surface  of  a  1:50  solution  of  carbolic  acid  below  the 
level  of  the  patient's  bed,  and  released,  thus  siphoning 
off  the  liquid  in  the  chest. 

PARACENTESIS  OF  THE  PERICARDIUM. 

Normally  the  pericardium  is  in  contact  with  the  chest 
wall  only  in  the  median  line  under  the  sternum  ;  but 
when  its  sac  is  distended  with  liquid  the  area  of  contact 
becomes  much  larger,  especially  by  extension  downward 
and  to  the  left.  The  heart  is  at  the  same  time  pressed 
upward  and  backward.  The  limits  of  the  pericardium 
can  be  ascertained  with  great  accuracy  by  percussion  and 
auscultation,  and  this  should  always  be  done  before  punc- 
turing. At  the  point  selected  for  puncture  the  pulsations 
(if  the  heart  should  be  imperceptible,  or  at  least  very 
faint,  and  it  should  be  absolutely  Hat  on  percussion.  It 
should  also  be  remembered  that  the  internal  mammary 
artery  runs  parallel  to  the  side  of  the  sternum,  and  a 
finger's  breadth  from  it. 

If  the  knife  is  used    the  tissues  must   be  divided    layer 
by  layer,  and  the  linger  should  always  be  introduced  into 

the  wound  before  the  pericardium  itself  is  incised,  to  make 

-lire  thai   tie'  heart   is  not  in  contact  with  it. 


C  H  A  P  T  E  R    V  I . 

OPERATIONS    UPON    THE    ABDOMINAL   WALL. 
STOMACH,    AND   INTESTINES. 

PARACENTESIS    OF  THE  ABDOMEN. 

In  order  to  avoid  injury  to  the  different  viscera,  and 
especially  to  the  internal  epigastric  artery,  which  runs 
from  the  middle  of  Poupart's  ligament  toward  the  um- 
bilicus, the  puncture  should  be  made  either  in  the  median 
line  midway  between  the  umbilicus  and  the  symphysis 
pubis,  or  midway  between  the  umbilicus  and  the  anterior 
superior  spine  of  the  ilium.  The  instrument  used  is  a 
trocar  and  canula  or  the  needle  of  an  aspirator.  The 
depth  to  which  it  shall  be  allowed  to  penetrate  is  regu- 
lated by  the  finger  placed  upon  its  side,  and  it  should  be 
plunged  in  sharply,  without  a  preliminary  incision,  at  the 
selected  point,  which  should  be  absolutely  flat  upon  per- 
cussion. As  there  is  a  possibility  of  syncope  occurring 
during  the  operation,  in  consequence  of  the  withdrawal 
of  pressure,  it  is  prudent  first  to  pass  a  broad,  many- 
tailed  flannel  bandage  about  the  abdomen,  crossing  its 
ends  behind,  so  that  an  assistant  standing  at  each  side  can 
draw  upon  them  and  tighten  the  bandage  as  the  liquid 
escapes.  It  is  usually  sufficient,  however,  to  have  an  as- 
sistant make  steady  pressure  with  one  hand  on  each  side 
of  the  abdomen.  During  the  operation  the  patient  should 
be  seated  or  inclined  toward  one  side. 

Should  hemorrhage  ensue,  the  attempt  must  first  be 
made  to  control  it  by  the  pressure  of  the  canula.  This 
failing,  the  entire  thickness  of  the  abdominal  wall  must  be 
pinched  up  and  compressed,  or,  in  extreme  cases,  the 
wound  must  be  enlarged  and  the  vessel  tied. 

379 


380  A&DOMtNAL   WALL  STOMAOB,  AND  INTESTINES. 

When  it  is  necessary  to  practice  paracentesis  upon  a 
pregnant  woman,  Ollivier  recommends  the  selection  of  the 
neighborhood  of  the  umbilicus  for  the  puncture  ;  Scarpa 
preferred  the  left  hypochondrium,  Velpeau  the  left  flank. 

LAPAROTOMY. 

If  time  permits,  preparatory  treatment  with  baths  and 
laxatives  is  continued  for  several  days,  and  in  a  female 
pelvic  case  the  vagina  is  rendered  as  aseptic  as  possible  by 
numerous  1  :  2000  bichloride  douches.  An  aperient  is 
given  the  evening  before  and  an  enema  in  the  morning  of 
the  operation  ;  the  patient  passes  water  or  is  catheterized 
immediately  before  being  placed  on  the  table.  The  prep- 
aration of  the  skin  surface,  the  surgeon,  the  attendants, 
instruments,  and  accessories  has  been  already  given. 
Sterilized  sponges,  round  and  fiat,  and  a  few  on  clamps  or 
handles,  and  pads  of  gauze  should  be  at  hand,  and  two 
sterilized  basins  of  warm  boiled  water,  one  to  contain  the 
clean  sponges,  and  the  other,  which  will  need  frequent 
changing,  to  rinse  the  soiled  sponges. 

All  parts  of  the  patient,  except  the  abdominal  snrfaee, 
all  the  tables  for  instruments,  sponges,  and  dressings,  and 
everything  not  previously  sterilized,  which  may  be  touched 
by  any  person  or  thing  concerned  in  the  wound,  are 
covered  with  sterilized  towels,  dry  or  wet  in  a  1  :  1000 
bichloride  of  mercury  solution.  The  numbers  of  clamps. 
sponges,  and  pads  are  written  down  immediately  before 
tin'  operation  and  verified  at  the  Close. 

The  incision  may  be  made  in  almost  any  part  of  the  ab- 
dominal wall,  but  is  most  often  median  and  should  divide 
tin-  tissues  layer  by  layer.  The  linea  alba  is  indistinct 
below  the  umbilicus,  and  if  the  incision  is  median  one  or 
other  rectus  sheath  will  generally  be  opened.  It  will  (hen 
be  found  convenient  immediately  to  unite  by  a  catgut 
suture   the  anterior  and    posterior  layers  of  the  opened 

sheath,  and  the  linea    alba    can  thus   be  more   quickly   re- 
formed at   the  close  of  the  operation.     The  preperitoneal 

fat   i-  recognized    and  all    bleeding   stopped.      The    perito- 
neum is  then  nicked  ami  the  opening  enlarged  with  blunt- 


LAPAROTOMY.  381 

pointed  scissors  to  the  length  of  the  abdominal  wound, 
which  must  be  made  large  enough  to  permit  easy  recogni- 
tion of  everything  as  it  is  encountered. 

The  position  of  the  bladder  must  be  remembered.  The 
field  of  operation  is  then  fenced  in  like  a  well  with  ster- 
ilized gauze  pads  or  Hat  sponges,  and  the  viscera  outside 
of  the  spot  in  question  entirely  hidden  in  the  rest  of  the 
unopened  abdominal  cavity. 

Pelvic  operations  are  much  facilitated  by  the  Tren- 
delenburg position — the  hips  elevated  above  the  shoulders, 
thus  causing  the  viscera  to  gravitate  out  of  the  way.  Each 
vessel  is  secured  separately,  if  possible,  before  division  ; 
there  must  be  no  cutting  in  the  dark  and  no  ligation  or 
large  masses  of  tissue  en  masse.  In  general  catgut  is 
preferable  to  silk  for  almost  all  pedicles  or  vessels. 

At  the  close  of  an  aseptic  laparotomy  the  perfectly  dry 
and  clean  wound  is  inspected  for  a  few  moments  to  be 
sure  that  there  is  no  more  bleeding  ;  the  clamps,  sponges, 
and  pads  are  removed  and  counted,  and  the  viscera  are 
then  allowed  to  resume  their  normal  positions.  A  flat 
sponge  or  pad  is  placed  over  the  viscera  in  the  abdominal 
wound  to  protect  them  and  to  absorb  such  blood  as  may 
flow  from  the  needle  punctures,  and  over  this  the  wound 
is  closed  by  various  methods. 

Silk,  silver  wire,  or  silkworm-gut  can  be  passed  through 
the  whole  thickness  of  the  abdominal  wall  and  periton- 
eum, from  half  an  inch  to  an  inch  from  the  margin  of  the 
wound,  and  about  the  same  distance  apart  ;  the  amount 
of  tension  necessary  in  tying  them  will  vary  with  the 
thickness  of  the  abdominal  wall,  its  laxity,  or  distention. 
Before  the  last  one  or  two  arc  tied  the  protecting  sponge 
is  withdrawn.  ( )r  the  peritoneum  may  be  first  sutured  over 
the  sponge  by  the  continuous  or  interrupted  catgut  suture 
and  the  sponge  withdrawn  before  it  is  entirely  closed, 
then  sutures  of  silk,  silver  wire,  or  silkworm-gut  are 
passed  ;i-  before,  but  only  through  the  parts  in  front  of 
the  peritoneum  ;  or  after  closing  the  peritoneum  and  re- 
moving the  sponge  the  overlying  parts  can  be  sutured 
with  catgut,  layer  by  layer.  Schede  l  recommends  buried 
1  Centrulblatt  fur  Chirurgie,  1893. 


382  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

sutures  of  silver  wire  for  all  the  layers  except  the  perito- 
neum and  skiu.  In  a  continuously  aseptic  wound  the 
sutures  should  not  be  removed  for  at  least  seven  days, 
and  then  with  every  antiseptic  precaution,  especially  if 
they  include  the  peritoneum. 

The  sutured  wound  may  he  covered  with  a  strip  of 
sterilized  rubber  tissue.  Iodoform  gauze  is  next  applied, 
and  over  this  layers  of  plain,  sterilized,  or  bichloride 
gauze. 

This  is  held  in  place  with  a  couple  of  transverse  strips 
of  adhesive  plaster  and  covered  with  a  layer  of  sterilized 
absorbent  gauze,  and  the  dressing  completed  by  a  broad 
abdominal  binder  or  a  broad  roller  bandage  applied  cir- 
cularly around  the  body  and  each  thigh  in  the  form  of  a 
spiea  to  prevent  slipping. 

The  sponges  contaminated  in  the  course  of  a  lapar- 
otomy, where  any  form  of  sepsis  or  noxious  element  is 
present,  should  be  kept  apart  from  the  others  as  far  as 
possible,  and  only  used  in  the  contaminated  area,  which 
latter  must  be  kept  separated  by  sterilized  sponges  or 
pads,  with  the  utmost  care,  from  the  rest  of  the  abdominal 
cavity.  The  towels  in  the  neighborhood  of  the  wound 
are  changed  or  covered  with  clean  ones  as  fast  as  they 
become  soiled,  and  the  wall  of  pads  or  sponges  surround- 
ing the  operation  area  must  be  replaced  by  fresh  ones 
when  they  become  saturated  with  the  noxious  materials, 
and  without  disturbing  the  position  of  the  protected 
viscera. 

The  wound  at  the  finish  is  made  as  clean  and  dry  as 
possible.  Wherever  peritoneum  has  been  divided  or 
stripped  up  it  should  be  replaced  and  secured  with  fine 
catgut  sutures.  There  may  remain  a  large  denuded  area 
liable  to  infection  or  studded  with  line  bleeding  points, 
as,  for  instance,  after  dissection  of  an  adherent  tumor. 
This  can  be  convenient!}'  treated  with  a  large;  square  of 
iodoform  or  sterilized  gauze,  the  center  of  which  is  tucked 
down  into  contact  with  this  area,  and  the  edges  brought 
out  of  the   abdominal    wound.      Other  strips  of  sterilized 

gauze  are  packed  into  this  as  into  a  bag.     If  pus  has  been 


OPERATIONS  ON   THE  INTESTINES.  383 

present  one  or  more  sterilized  drainage  tubes  of  rubber  or 
glass  with  lateral  perforations  must  be  run  down  from  the 
surface  to  the  bottom  of  the  infected  region.  Sometimes 
a  strip  of  gauze  is  packed  inside  of  the  tubes  to  aid  the 
escape  of  fluid  on  the  principle  of  capillarity.  And  this 
strip  is  frequently  changed  with  every  antiseptic  pre- 
caution. 

In  female  pelvic  cases  it  may  be  desirable  to  pass  a 
tube  through  a  counter-opening  in  the  vault  of  the  vagina. 
Hence  the  necessity  of  the  preliminary  cleansing  of  the 
vagina  in  every  case  where  there  is  even  a  possibility  of 
pelvic  complications.  The  vagina  is  afterward  packed 
with  sterilized  or  iodoform  gauze,  the  vulva  covered  with 
an  antiseptic  dressing,  and  the  patient  catheterized  for 
several  days  subsequently.  After  inserting  the  tubes, 
and  with  as  little  displacement  of  the  protected  viscera  as 
possible,  the  sponges  or  pads  are  removed  and  counted 
and  their  places  supplied  by  a  light  packing  of  strips  of 
iodoform  or  simple  sterilized  gauze,  the  ends  of  which 
protrude  through  the  incision.  Before  packing  the  wound 
it  may  be  advisable  to  flush  out  the  infected  region  with 
warm  boiled  water  or  sterilized  salt  solution,  and  some- 
times a  large  part  of  or  the  whole  peritoneal  cavitv  is 
thus  treated  and  counter-openings  for  drainage,  with 
packing,  are  made. 

At  the  close  of  the  operation  the  peritoneum  is  first 
sutured  over  a  sponge  or  pad  down  to  the  point  of  exit  of 
the  tubes  and  packing,  and  the  sponge  then  removed. 
The  overlying  parts  are  drawn  together  to  a  correspond- 
ing extent  with  silk,  silkworm-gut,  or  silver  wire  passed 
through  everything  in  front  of  the  peritoneum,  and  a 
dressing  which  covers  the  euds  of  any  tubes  is  then  ap- 
plied, as  in  an  aseptic  case. 

OPERATIONS  ON  THE  INTESTINES. 

Anatomy.  (Fig.  1ST.) — The  parts  of  the  intestines 
which  have  a  mesentery  are  completely  covered  by 
peritoneum  except  along  a  narrow  interval  where  the 
laminae  of  the  mesentery  diverge  to  encircle  the  bowel 


384  ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 


Fig.  187. 


(  Fig.  187,  2).  Thus  the  outer  wall  of  the  gut,  along  the 
line  where  the  mesentery  meets  it,  is  formed  by  a  strip  of 
the  muscular  coat  about  five-sixteenths  of  an  inch  wide 
(Fig.  187,  3),  and  this  is  apt  to  be  the  weak  point  in  a 
row  of  sutures  involving  this  portion  of  the  circumference 
of  the  bowel.  The  arteries  in  the  mesentery  form  freely 
anastomosing  loops  from  which,  close  to  the  intestine, 
arise  straight  vessels  with  little  or  no  intercommunication, 
and  having  a  circular  and  fairly 
well-defined  distribution,  so  that, 
while  a  portion  of  the  mesentery 
at  a  distance  from  the  intestine  may 
be  destroyed  with  comparative  im- 
punity, an  injury  to  the  smallest 
part  in  immediate  proximity  to 
the  gut  involves  a  probability  of 
sloughing  of  a  corresponding  ex- 
tent of  intestine. 

An  anatomical  knowledge  of 
the  mesentery  is  of  value  in  a 
search  for  the  upper  or  lower  end 
of  the  small  intestine.  The  pari- 
etal attachment  of  the  mesentery 
extends  from  the  left  side  of  the 
second  lumbar  vertebra  downward 
to  the  right  iliac  fossa,  and,  if  the 
finger  trace  the  left  layer  of  the 
mesentery  of  a  loop  of  intestine 
back  toward  the  spine,  it  passes  off 
toward  the  left  side  of  the  abdo- 
men, and  the  right  layer  will  lead 
to  the  right  side  of  the  abdomen.  This  will  show  which 
end  is  the  upper  or  Lower  iii  any  particular  loop.  Also 
the  upper  part  of  the  small  intestine  has  a  greater  di- 
ameter, is  thicker  walled  (valvulae  conniventes),  and  more 
vascular  than  the  lower  part.  The  coats  of  the  intestine 
from  without  inward  are:  (1)  the  peritoneal,  (2)  the  lon- 
gitudinal, (3)  circular  muscular,  (-T)  the  submucosa,  a 
tough  fibrous  membrane,  (5)  the  muscularis  mucosae,  and 


Section  of  smalt  intestine  and 
mesentery.  1.  Mesentery.  'J. 
Triangular  space  between  di- 
verging layers  of  the  mesentery. 
3.  its  base  resting  on  m,  tne 
muscular  coal  of  the  gut,  /'. 
Peritoneum,  m.  m.  M  u  co  ii  a 
membrane. 


OPERATIONS  ON  THE  INTESTINES.  385 

(6)  the  mucosa,  the  latter  making-  up  about  two-thirds  of 

the  thickness  of  the  wall. 

Unless  the  suture  includes  a  shred  of  the  submucosa  it 
is  very  apt  to  tear  out.  This  coat  is  recognizable  by  the 
increased  resistance  which  it  offers  to  the  passage  of  the 
needle  after  the  peritoneal  and  muscular  layers  have  been 
transversed.1  The  colon  and  sigmoid  flexure  are  recog- 
nizable by  their  corrugations,  their  more  or  less  fixed 
positions,  the  appendices  epiploic^  which  are  most  numer- 
ous in  the  transverse  colon,  and  by  the  longitudinal  bands 
of  muscular  fibers.  The  anterior  band  is  the  largest  and 
most  prominent,  and  lies  in  front  of  the  caecum,  colon, 
and  sigmoid  flexure.  In  the  transverse  colon  it  corre- 
sponds to  the  attachment  of  the  great  omentum,  and  in 
the  ascending  colon  and  caecum  it  is  the  unfailing  guide 
to  the  appendix  vermiformis,  from  the  attachment  of 
which  to  the  caecum  the  anterior,  inner,  and  posterior 
longitudinal  bands  all  start.  The  appendix  lies  about 
opposite  a  point  indicated  on  the  abdomen  by  the  center 
of  the  line  passing  from  the  right  anterior  superior  spine 
of  the  ilium  to  the  umbilicus.  It  may  or  may  not  have 
a  mesentery  and  commonly  lies  behind  the  lower  end  of 
the  ileum,  and  often  in  close  relation  with  the  iliac  ves- 
sels and  ureter,  and  is  not  infrequently  found  in  the  pelvis. 

To  be  successful  the  closure  of  an  intestinal  wound 
must  be  water-tight,  and  no  stitch  may  perforate  all  the 
coats  ;  there  must  be  no  subsequent  giving  way  of  any 
part  of  the  wound,  either  from  slipping  of  a  suture  or 
ulceration  or  sloughing  at  the  site  of  its  insertion,  and  the 
lumen  of  the  bowel  must  not  be  unduly  narrowed.  A 
round  sewing  needle  and  black  silk  are  generally  used. 

The  continuous  suture  is  applied  like  the  ordinary  con- 
tinuous suture  already  described,  and  is  carried  a  short 
distance  beyond  the  extremities  of  a  longitudinal  wound. 
The  needle  penetrates  the  peritoneal  and  muscular  coats 
of  the  intestine,  catching  up  a  few  fibers  of  the  submu- 
cosa, but  nowhere  perforating  the  mucosa.  The  stitches  are 
placed  at  intervals  of  about  a  quarter  of  an  inch  close  to 
'Enilsted  :    American  Journal  Medical  Sciences,  1887,  p.  4:'.f>. 


386   ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

the  margins  of  the  wound,  which  are  turned  in  to  bring 
the  peritoneal  surfaces  in  apposition. 

The  right-angled  continuous  suture  (Fig.  188)  differs 
from  this  last  only  in  having  the  buried  portions  parallel 
to  the  line  of  the  wound  and  the  exposed  portions  at  right 
angles  to  it. 

The  continuous  suture  can  be  rapidly  applied,  and  is 
useful  for  reinforcing  weak  points  in  an  interrupted  suture 


Fig.  ism. 


11  8 

Right-angled  continuous  intestinal  suture.     (Geeig  Smith.) 

line,  hot  it  is  inapplicable  for  closing  a  complete  trans- 
verse division  of  the  bowel.  All  parts  of  the  continuous 
suture  may  not  be  drawn  equally  tight,  and  the  contrac- 
tion of  the  gill    tends  to  loosen  if  and  allow  the  wound  to 

Tin  interrupted  suture  oj  Lembert  is  the  most  approved 
and  generally  used  intestinal  suture.  The  needle  pene- 
trates a  fold  of  tln>  peritoneal,  muscular,  and  a  few  shreds 


OPERATIONS   ON   THE  INTESTINES. 


387 


of  the  submucous  coat  of  the  gut  on  opposite  sides  of  the 
wound,  the  margins  of  which  are  inverted  and  the  perito- 
neum brought  together.  The  sutures  .should  be  placed 
about  on  eighth  of  an  inch  from  the  margin  of  the  wound 


Fig.  189. 


Diagram  representing  the  method  of  inserting  the  Czerny-Lenibert  suture.    The 
Lembert  suture  is  below,  the  Czerny  at  the  cut  edge, 

and  about  the  same  distance  apart,  and  each  should  grasp 
a  fold  of  the  intestine  about  one-tenth  or  one-twelfth  of 
an  inch  wide.      None  must  touch  the  mucosa. 


Fig.    llio. 


Ualsted  quill  suture  for  the  iutestiui 


388   ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 

(  \<r nifs  method  consisted  of  an  interrupted  line  of 
sutures  passing  through  all  coats  of  the  intestine  and  tied 
inside.  A  second  row  of  Lembert  sutures  is  then  added 
to  bring  the  peritoneal  surfaces  on  each  side  of  the  wound 
in  contact  over  the  first  row  of  sutures,  Czerny's  suture 
is  now  generally  passed  through  all  coats  except  the  outer 
one. 

Halsted's  <]>tilt  suture*  (Fig.  1!'<))  will  hear  a  eonsider- 
ahle  strain.  It  is  a  modification  of  Lembert's  method. 
The  needle  penetrates  the  superficial  coats  of  the  gut  twice 
on  eacli  side  of  the  wound  and  is  then  knotted. 

CIRCULAR  ENTERORRHAPHY. 

This  is  the  usual  term  for  designating  an  end-to-end 
suture  of  the  intestine  from  which  a  segment  has  been  re- 
moved. 

Operation. — The  loop  of  intestine  is  carefully  drawn 
out  of  the  abdomen  and  surrounded  by  warm  pads  or 
sponges  while  the  opening  into  the  peritoneal  cavity  is 
protected  by  a  gauze  or  sponge  packing.  The  feces  are 
squeezed  out  of  the  loop,  and  about  an  inch  above  and  be- 
low the  limits  of  the  segment  of  gut  to  be  removed  the  in- 
testine is  constricted  tightly  enough  to  close  its  lumen, 
either  by  the  lingers  of  an  assistant  or  by  one  of  the 
specially  designed  clamps,  or  by  a  strip  of  iodoform 
gauze,  which  is  passed  through  a  small  hole  made  in  the 
mesentery  by  ;i  bllini  instrument  at  :i  little  distance  from 
the  Mnt  and  tied  snugly  about  it.  After  thoroughly  pro- 
tecting the  exposed  peritoneal  surface,  at  the  spot  selected 
on  the  lower  side  of  the  disease,  the  intestine  is  divided 
squarely  across  and  its  interior  immediately  irrigated  with 
warm  boiled  water.  With  :i  dean  pair  of  scissors,  the 
mesentery  of  the  diseased  part  i>  cut  as  close  to  the  gut 
:i-  possible  up  to  the  intended  upper  point  of  the  intestinal 
division,  where  tin'  intestine  is  then  cut  squarely  across, 
and  the  interior  below  the  constricting  gauze  band  im- 
mediately irrigated  ;is  before. 

1  \  1 1 1 •  ■  i  j <  ;i  1 1  Journal  Medical  Sciences,  October.  1887. 


<  li;<  7  7..  I  /,'   ENTERORRK I  /'//)' 


389 


The  divided  mesentery,  if  broad,  may  be  partly  resected 
triangularly  and  its  sides  sutured  together.  Bleeding  is 
checked  I>y  separate  Ligation  with  tine  catgut  of  each 
vessel.  Meanwhile  every  portion  of*  peritoneum  is 
scrupulously  protected  from  infections  matter,  and  before 
the  next  step  instruments  which  have  touched  infections 

Fig.  101. 


( Jirenlar  enterorrhaphy. 


matter  or  the  interior  of  the  intestine  arc  discarded  and 
the  hands  carefully  washed. 

The  ends  of  the  gut  are  then  brought  into  apposition 
and  the  mucous  membrane  united  evenly  all  around  by  a 
continuous  catgut  or  silk  suture.  The  mesenteric  border 
of  the  gut  is  drawn  together  by  a  Lembert  silk  suture,  and 
then  the  opposite  free  border.  By  gentle  traction  on  the 
ends  of  these  sutures  (Fig.  191)  the  gut  is  flattened  out 
and  on  the   line  thus   indicated   the  necessary  number  of 


390   ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

Lembert  sutures  arc  added,  but  uot  tied  till  the  last  is  in 
place.  The  peritoneal  surfaces  must  be  very  carefully 
brought  into  contact  at  the  mesenteric  attachment  of  the 
bowel  to  avoid  leakage  into  the  areolar  tissue  between  the 
diverging  layers  of  the  mesentery  ;  but  weak  points  must 
not  be  so  reinforced  by  continuous  or  interrupted  sutures 
that  the  lumen  of  the  intestine  becomes  unduly  narrowed. 
The  fold  of  detached  mesentery  is  drawn  together  at  its 
cut  edge  with  catgut,  and  if  long  enough  it  is  sometimes 
advised  to  suture  its  peritoneal  surface  over  the  line  of  in- 
testinal union  as  far  as  it  will  reach  without  tension. 

Scnn  sutures  the  great  omentum  over  the  outer  row  of 
Lembert  sutures  and  has  thus  covered  a  circular  enteror- 
rhaphy  with  a  detached  omental  graft  an  inch  wide  and 
long  enough  to  encircle  the  bowel.  '  The  parts  arc  again 
irrigated  with  warm  boiled  water,  the  intestinal  clamps  or 
gauze  bands  are  removed  together  with  the  protective 
sponge  packing,  and  after  returning  the  gut  to  the  abdo- 
men the  parietal  wound  is  closed  in  the  usual  way. 

INTESTINAL  ANASTOMOSIS. 

This  is  the  formation  ofa  lateral  communication  between 
the  lumina  of  two  different  portions  of  the  gut.  Owing  to 
the  contraction  in  the  calibre  of  the  intestine  which  follows 
circular  enterorrhaphy,  this  operation  of  anastomosis  is 
frequently  adopted  in  its  place;  though  it  was  originally 
introduced  as  a  palliative  means  of  relieving  an  irremov- 
able obstruction  of  the  bowel  by  uniting  the  parts  above 
and  below  the  obstruction. 

Operation. — Above  and  below  the  obstructions  healthy 
portions  of  the  gut  are  selected  which  can  be  brought  into 
apposil  ion  without  tension,  along  several  inches  of  surface. 
The  rest  of  the  peritoneal  cavity  is  walled  oil' wit  h  sponges, 
and  if  possible  the  selected  loops  of  intestine  arc  drawn 
out    of  the  abdomen  ami    surrounded    by   warm   cloths. 

About  one-quarter  of  an  inch  to  the  under  side  of  the 
center  of  the  Convex   i'vrc    border  as    \\\c    intestine  lies  e\- 

■Trans.   Im.  Med.  Cong.,  9th  sessi Washington,   L887,  Vol.   I., 

p.  485. 


INTESTINAL   ANASTOMOSIS. 


391 


posed,  the  apposing  loops  arc  united  for  about  five  inches 
by  a  continuous  silk  suture  through  the  peritoneal  coats 
alone.  About  an  inch  above  and  below  this  suture  line, 
on  each  loop,  an  iodoform-gauzc  band  is  passed  through 
the  mesentery,  at  a  little  distance  from  the  intestine,  and 
tied  around  the  gut  just  tightly  enough  to  prevent  the  en- 
trance of  fecal  matter.  Each  loop  is  then  opened  along 
its  convex  free  border  for  nearly  the  same  distance  (about 
four  inches)   parallel  to  and  immediately  in  front  of  the 

Fig.  192. 


Senn's  plates,  n,  a.  Lateral  or  fixation  suture,  b,  ft.  End  or  apposition  suture. 
Thread  passed  through  2  is  brought  out  through  1,  and  thai  through  4  out  through 
3.    (Treves.) 

row  of  sutures  already  in  place.  The  openings  should 
terminate  opposite  each  other  about  half  an  inch  short  of 
the  end  of  the  suture  line.  The  interior  of  each  isolated 
loop  is  immediately  irrigated  clean  with  warm  boiled 
water  while  the  exposed  peritoneal  surface  is  protected  as 
far  as  possible. 

Soiled  towels  or  protecting  sponges  are  then  replaced 
by  clean  ones,  anything  which  has  touched  the  interior  of 
the  intestine  or  its  contents  is  discarded  and  the   hands 


392   ABDOMINAL   WALL,  STOMACH,  AM)  TNTESTINES. 

carefully  washed.  Alter  this  the  edges  of  the  two  open- 
ings are  united  to  each  other  all  around  by  a  continuous 
catgut  or  silk  suture.  The  exposed  parts  are  again  irri- 
gated   and    the    protectives     and     instruments     changed. 

Fig.  193. 


Intestinal  anastomosis,  with  Senn's  plates,    ».  u.  Lateral  or  fixation  sutures,    /», 
b    End  or'apposition  sutures     c.      Posterior  sutures.    (Senn.) 


Finally,  a  continuous   silk    hiIiiiv,  beginning   and    ending 
with    the    one   already  placed,  is   applied    along   the   skin- 

Bide  of  the  opening. 

In  cases  of  enterectomy  the  segment  of  gut  to  be  re- 
moved i~  excised  :i~  described  in  circular  enterorrhaphy. 


INTESTINAL   ANASTOMOSIS  393 

Theopen  endsofthe  intestine  are  then  turned  in  to  bring 
peritoneal  surfaces  into  contact,  and  closed  by  a  continu- 
ous silk  suture  curried  hack  and  forth  once  or  twice  and 
in  no  spot  entering  the  mucosa.  The  constricting  gauze 
hands  are  removed  from  the  intestine  and  the  anastomosis 
proceeded  with. 

Senn  '  reinvented  and  greatly  improved  the  forgotten 
method  of  uniting'  different  portions  of  the  gut  laterally 
by  means  of  perforated  absorbable  plates  which  bring 
into  contact  broad  areas  of  peritoneum  around  a  central 
opening. 

Two  contiguous  loops  of  intestine  are  opened  to  the 
same  extent  longitudinally,  on  the  side  opposite  the  at- 
tachment of  the  mesentery,  and  sufficiently  to  admit  the 
plates  edgewise.  After  introduction  the  plates  arc  rotated 
enough  to  make  their  perforations  correspond  to  the  open- 
ings made  in  the  intestine.  About  a  quarter  of  an  inch 
from  the  margins  of  the  openings  on  each  side,  the  wall 
of  the  intestine  is  perforated  by  the  two  lateral  sutures 
which  are  armed  with  needles.  The  other  two  sutures 
are  tied  across  the  extremities  of  the  openings  without 
perforating  the  intestinal  wall. 

The  sutures  serve  the  double  purpose  of  holding  the 
parts  in  apposition  and  keeping  the  openings  patent. 

After  the  parts  are  brought  together  union  is  further 
secured  by  a  continuous  or  interrupted  suture  through  the 
peritoneal  coat  around  the  margins  of  the  plates.  The 
plates,  which  Senn  made  of  decalcified  bone,  are  supposed 
to  become  absorbed  or  disintegrated  between  the  third 
and  tenth  days. 

This  method  has  been  largely  abandoned  in  this  coun- 
try on  account  of  the  later  eontraction  of  the  fistula. 

The  Murphy  "  button  "  has  attained  great  and  growing 
popularity  as  a  means  of  uniting  different  portions  of  the 
intestine.  A  description  of  the  device  and  its  application 
will  be  found  in  the  paragraphs  on  cholecystenterostomy. 
Quite  recently  a  satisfactory  substitute  has  been  found  in 

'Trans.  Int.  Med.  Cong.,  9th  session,  Washington,  1887,  Vol.  I., 
p.  435. 


304   ABDOMINAL   WALL,  STOMACH,  AND  fNTESTJNES. 

a  piece  of  raw  potato  perforated  and  fashioned  into  simi- 
lar shape. 

Various  methods  have  been  devised  for  uniting  por- 
tions of  gut  of  unequal  diameter,  but  they  have  now  been 
generally  superseded  by  closing  the  transversely  divided 
ends  and  performing  lateral  anastomosis. 

Union  of  Divided  Intestine  by  Tntussusception.  (Maun- 
sell.)1 — The  disease  is  excised  by  transverse  division  of 
the  gut  as  described  in  circular  enterorrhaphy.  The  cut 
ends  of  the  intestine  are  united  by  one  suture  through  the 
entire  wall  at  the  point  of  the  mesenteric  attachment  and 


Fig.  194. 


Maunsell's  method;   fir<t  two  Butures  broughl  oul  through  t lie  incision  in  the 
lowei  segment. 

by  another  at  the  point  directly  opposite.  The  portion  of 
intestine  which  lies  on  the  lower  or  rectal  side  of  the  line 
of  division,  starting  about  an  inch  from  this  line,  is 
opened  longitudinally  on  its  convex  free  border  for  about 
two  inches.  Through  this  incision  the  long  ends  of  the 
two  sutures  are  passed  and  the  gut  invaginated  and  its 
partly  united  cut  ends  drawn  out  through  the  opening. 
(Figs.  194  and  195.)  The  union  of  these  cut  ends 
i-  then  completed  by  interrupted  sutures  of  fine  silk  in- 
eluding  the  entire  thickness  of  the  wall  close  to  the  cut 
edge.  The  intestine  is  then  withdrawn  from  the  opening 
and  the  longitudinal  slit  closed  by  Lembert  sutures. 
•Aincr.  Journ.  Med.  ScL,  1892,  Vol.  103,  i>.  245. 


NELATON'S   OPERATION. 


395 


ENTEROSTOMY, 
[nstead  of  excision  of  a  portion  of  the  gut  with  imme- 
diate restoration  of  its  continuity  by  circular  enterorrhaphy 
or  lateral  anastomosis,  circumstances  such  as  an  uncertain 
amount  of  gangrene,  the  had  condition  of  the  patient,  etc., 
may  require  that  the  bowel  be  simply  freed  from  its  con- 
striction and  the  damaged  part  left  outside  the  abdomen 
till  the  slough  separates.  It  is  fastened  to  the  margins  of 
the  abdominal  wound  by  a  couple  of  sutures.  In  course 
of  time  it  is  treated  by  the  method  described  for  the  closure 
of  an  artificial  amis. 


Maunsell's  method;  protruding  ends  ready  for  suture. 

RIGHT  INGUINAL  ENTEROSTOMY   I NELATON  S 

OPERATION). 
As  long-  ago  as  1819,  it  was  proposed  to  establish  an 
artificial  amis  in  the  ileum  in  ease  the  intestinal  obstruction 
could  not  be  found  or  removed  by  laparotomy  ;  but  Nela- 
ton  was  the  first  (1840)  to  substitute  this  for  the  other 
operation,  giving  up  the  search  after  the  obstruction  en- 
tirely. His  theory  was  that  many  obstructions  would 
relieve  themselves  in  time,  if  a  temporary  outlet  should 
be  furnished  to  the  accumulation  above;  in  some  cases, 
on  the  other  hand,  where  the  obstruction  is  permanent,  an 


396   ABDOMINAL   WALT,.  STOMA  elf.  AND  INTESTINES. 

artificial  anus  in  the  ileum  meets  the  "vital  indication 
perfectly — for   example,   when   the  obstruction   is  in  the 
lower   portion    of  the   small    intestine;    while   in   others, 
again,  where   the  occlusion  occurs  below  the  ileo-caecal 

valve,  and  the  relief  afforded  would,  consequently,  be  im- 
perfect, the  obstruction  is  usually  due  to  malignant  dis- 
ease, which  in  itself  would  soon  destroy  life  and  against 
which  neither  laparotomy  nor  any  other  operation  would 
avail. 

It  is  also  essential  to  the  proper  nourishment  of  the 
patient  that  the  greater  part  of  the  small  intestine  should 
remain  serviceable;  that  is,  that  the  opening  should  be 
made  in  the  lower  part  of  the  ileum.  ( )f  course,  this  can- 
not be  accomplished  when  the  obstruction  is  situated  high 
up,  but,  in  other  cases,  Nelaton  found  that  the  intestinal 
loops  nearest  the  obstruction  always  occupied  the  right 
iliac  fossa,  and  he,  therefore,  cut  through  the  abdominal 
wall  just  above  the  outer  half  of  Poupart's  ligament  on 
the  right  side,  and  opened  the  first  loop  that  presented 
in  the  incision.  The  portion  of  the  intestine  below  an 
obstruction  is  always  empty  and  shrunken,  and  docs  not 
come  into  contact  with  the  anterior  abdominal  wall,  so 
that  there  is  no  danger  of  making  the  opening  in  it  by 
mistake.  It  occasionally  happens  when  the  obstruction 
is  situated  in  the  colon  that  the  distended  caecum  fortu- 
nately presents  in  the  incision,  and  the  artificial  anus  is 
established  below  the  ileo-caecal  valve. 

Operation. — Make  an  incision  parallel  to  and  about  an 
inch  above  Poupart's  ligament,  beginning  at  the  anterior 
superior  spine  of  the  ilium  and  ending  opposite  the  in- 
ternal abdominal    ring. 

Divide  the  tissues  layer  by  layer,  pick  up  and  nick  the 
peritoneum  and  open  it  for  about  one  and  a-half  inches. 
The  first  distended  intestinal  loop  which  presents  is  drawn 
out  till  its  free  border  is  on  a  level  with  the  skin,  and  re- 
tained by  two  silk  suture.-,  which,  at  the  same  time,  draw 

together  the  extremities  of  the  abdominal  wound.  Bach 
suture  passes  through  all  the  parietal  tissues  and  the  peri- 
toneal and  muscular  coats  of  the  intestine.     The  skin  ami 


COLOSTOMY  397 

bowel  are  closely  united  all  around  by  interrupted 
sutures,  none  of  which  must   enter  the  lumen  of  the  gut. 

The  suture  line  is  covered  by  a  strand  of  iodoform  gauze 
pasted  down  with  flexible  collodion,  and  the  center  of  the 
protruding  intestinal  wall  opened  in  its  long  axis  for  about 
half  an  inch. 

The  parietal  peritoneum  can  be  drawn  out  and  stitched 
to  the  skin  before  the  bowel  is  sutured  in  place,  thus 
bringing  into  contact  a  larger  surface  of  parietal  and  vis- 
ceral  peritoneum. 

COLOSTOMY. 

Left  Inguinal  Colostomy. — Make  an  incision  between 
two  and  three  inches  long,  according  to  the  thickness  of 
the  abdominal  wall,  parallel  to  and  about  an  inch  above 
Poupart's  ligament,  with  its  center  at  the  level  of  the  an- 
terior superior  spine  of  the  ilium,  or  a  little  lower.  The 
tissues  are  divided  layer  by  layer,  the  peritoneum  opened, 
and  the  skin  and  parietal  peritoneum  united  by  a  few 
sutures,  not  including  the  muscles.  The  sigmoid  flexure, 
which  is  recognized  by  its  anterior  longitudinal  band,  its 
convoluted  surface,  or  appendices  epiploic*,  is  drawn  into 
the  opening  and  retained  by  a  couple  of  silk  or  silkworm- 
gut  sutures  passed  about  two  inches  apart  through  both 
lips  of  the  wound  at  its  extremities  and  the  longitudinal 
band  of  the  colon.  The  gut  is  then  closely  united  to  the 
margins  of  the  wound  by  fine  silk  sutures  passing  through 
the  already  joined  skin  and  peritoneum  and  the  outer 
coats  of  the  intestine.  No  suture  should  penetrate  to  its 
interior.  The  amount  of  the  circumference  of  the  gut  to 
lie  external  to  the  sutures  is  about  half  an  inch  when  the 
operation  is  for  the  temporary  relief  of  obstruction.  For  a 
permanent  artificial  anus  two-thirds  of  the  circumference 
of  the  bowel  should  lie  anterior  to  the  suture  line.  The 
center  of  the  exposed  intestinal  wall  is  then  opened  longi- 
tudinally with  a  knife  or  thermo-eautery  for  about  half  an 
inch  and  drainage  tubes  inserted. 

Before  opening  the  bowel  the  suture  line  can  be  cov- 
ered with  a  strip  of  iodoform  gauze  pasted  over  with  flexi- 


398   ABDOMINAL   WALL.  STOMACH,  AND  INTESTINES. 

ble  collodion.  It"  there  is  no  urgency  the  opening  can  !><■ 
deferred  for  five  or  six  days  till  adhesions  have  shut  oft" 
the  general  peritoneal  cavity. 

Some  surgeons  prefer  not  to  unite  the  skin  and  parietal 
peritoneum,  but  to  suture  the  outer  coats  of  the  intestine 
to  the  skin  alone.  The  gut  adhering  to  all  parts  between 
the  skin  and  parietal  peritoneum  is  thought  less  liable  to 
retract  than  it'  adherent  only  to  the  intervening  parietal 
peritoneum  with  its  movable  subserous  areolar  tissue. 

Maydl  '  hangs  the  intestine  on  a  sterilized  rod  passed 
through  the  mesentery  close  to  the  bowel  and  laid  on  the 
skin  transversely  to  the  wound.  The  apposing  walls  of 
this  loop  are  united  by  a  few  interrupted  sutures  through 
the  peritoneal  coats  and  the  rest  of  the  walls  left  to  ad- 
here to  the  abdominal  wound  ;  but  if  immediate  opening 
is  intended,  the  sutures  are  passed  through  the  skin  and 
peritoneum  around  the  margins  of  the  incision,  and 
through  the  serous  and  muscular  coats  of  the  nut.  com- 
pletely shutting  off  the  peritoneal  cavity.  The  exposed 
wall  of  the  intestine  is  opened  transversely  for  one-third 
of  its  circumference,  and  drainage  tubes  placed  within  it. 
Two  or  three  weeks  later  the  bowel  is  entirely  divided  on 
tin-  line  and  the  cut  edges  sutured  to  the  skin  for  a  per- 
manent   artificial  anus. 

If  the  operation  is  merely  temporary  the  intestine  is 
Opened  longitudinally,  and  when  adhesion-  have  formed 
the  rod  is  withdrawn,  and  the  bowel  retracts  and  the 
Hstula  sometimes  closes  spontaneously. 

Right  inguinal  colostomy  only  diners  from  the  last  oper- 
ation in  that  t he  abdominal  incision  i>  placed  on  the  righl 
Bide  and  the  caecum  is  opened  instead  of  the  sigmoid 
flexure. 

Iii  either  righl  or  left  inguinal  colostomy  the  opening 
in  the  abdominal  wall  may  be  made  by  the  " inter-mus- 
cular" method  devised  bv  Dr.  McBurney  for  operations 
upon  t he  appendix  (q.  v.).  It  seem-  probable  that  a  certain 
amount  of  sphincteric  control  of  the  opening  may  be  thus 
obtained. 

■Central!),  i.  <  Mr..  1---.  So.  24. 


COLOSTOMY.  309 

Lumbar  Colostomy. — This  operation  was  first  suggested 
by  Callisen,1  in  1797,  as  a  substitute  for  Littre's  or  in- 
guinal colostomy  with  a  view  to  avoiding  the  dangers  in- 
cidental to  an  incision  through  the  peritoneum.  He  pro- 
posed to  open  the  descending  colon  in  the  posterior  third 
of  its  periphery,  where  it  is  not  covered  by  peritoneum. 
So  far  as  known,  Amussat  was  the  first  to  perform  the 
operation  in  1839,  and  although  he  opened  the  ascending 
colon,  and  by  a  transverse  instead  of  a  vertical  incision, 
the  operation  was  essentially  the  same  as  that  proposed 
by  Callisen.  All  that  portion  of  the  descending  colon 
which  lies  above  the  crest  of  the  ilium  is  usually  uncov- 
ered by  peritoneum  on  its  posterior  aspect,  and  although 
the  actual  breadth  of  the  uncovered  portion  varies  with 
the  degree  of  distention  of  the  bowel,  it  usually  amounts 
to  one-third  of  the  entire  circumference,  and  is  bounded 
on  each  side  by  one  of  the  three  longitudinal  bundles  of 
unstriped  muscle  characteristic  of  the  colon.  In  position 
it  corresponds  nearly  to  the  outer  border  of  the  quadratus 
lumborum,  and  very  exactly  to  a  vertical  line  drawn  a 
full  half  inch  behind  the  center  of  a  transverse  one,  unit- 
ing the  anterior  and  posterior  superior  spines  of  the  ilium 
(Mason).  On  the  right  side  (ascending  colon)  the  un- 
covered portion  is  more  often  smaller,  and  the  existence 
of  an  actual  meso-eolon,  although  rare,  is  yet  more  fre- 
quent than  upon  the  left  side. 

Callisen  proposed  a  vertical  incision  a  little  external  to 
the  outer  border  of  the  erector  spina?  ;  Amussat  made  a 
transverse  one  midway  between  the  last  rib  and  the  crest 
of  the  ilium,  while  Baudens  used  an  oblique  one  passing 
downward  and  outward  at  an  angle  of  45°.  The  latter 
is  to  be  preferred,  because,  while  giving  sufficient  room, 
it  inflicts  less  injury  upon  the  vessels  and  nerves  of  the 
parts,  the  general  direction  of  which  is  the  same  as  that 
of  the  incision. 

The  operation  is  performed  as  follows  :  The  patient  is 
etherized,  and   placed  in  a   position   midway  between   the 

1  Erskine  Mason:  Six  Cases  of  Lumbar  Colotomy,  A  hut.  Journ.  of 
Med.  Sciences,  <  M.,  1873. 


400  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

prone  and  right  lateral,  a  hard  cushion  being  placed  trans- 
versely under  the  right  loin  to  keep  the  spine  straight  or 
slightly  curved  toward  the  left.  Mason  says  the  opera- 
tion has  been  performed  with  the  patient  seated  and  lean- 
ing forward  over  the  back  of  another  chair,  local  anaes- 
thesia being  obtained  by  means  of  the  ether  spray.  The 
anterior  and  posterior  superior  spines  of  the  left  ilium  are 
then  recognized,  and  a  vertical  line  drawn  upward  from  a 
point  one-half  to  three-quarters  of  an  inch  behind  the 
center  of  a  transverse  line  drawn  from  one  to  the  other. 
This  vertical  line  should  be  marked  with  iodine  or  nitrate 
of  silver,  in  order  to  serve  as  a  guide  during  the  operation. 

If  the  occlusion  of  the  intestine  has  not  been  complete, 
and  there  is  reason  to  suppose  that  the  colon  will  be  found 
empty,  it  may  now  be  distended  by  injecting  air  through 
the  rectum. 

A  transverse  or  an  oblique  incision  four  or  five  inches 
long  is  then  made,  its  center  lying  in  the  vertical  line 
above  mentioned  midway  between  the  last  rib  and  the 
ilium.  The  underlying  tissues  arc  recognized  and  divided 
layer  by  layer,  until  the  fascia  transversalis  and  quadratus 
lumborum  arc  reached.  The  former  is  next  carefully  di- 
vided, and,  if  the  adipose  tissue  covering  the  colon  does 
not  then  appear  in  the  wound,  the  latter  should  be  enlarged 
on  the  inner  side  by  dividing  the  outer  fibers  of  the  quad- 
ratic. The  intestine  must  alwavs  be  sought  for  in  the 
angle  of  the  wound  nearest  the  spine,  and  whenever  it  is 
desired  to  increase  its  exposed  area  this  must  be  done  in 
the  same  direction. 

The  colon  can  usually  be  recognized  l>v  its  distention 
and  shape,  and   possibly  by  one  of  its  longitudinal  bands. 

Two  stout  ligatures  arc  next  passed  by  means  of  curved 
needles  through  the  presenting  portion  of  intestine  and 
used  to  draw  it  up  into  the  wound,  and  fasten  it  to  the 
skin  at  the  sides  of  the  incision.  The  wound  is  then 
filled  with  sponges   or   gauze,  and  the    bowel    opened  by  a 

longitudinal  or  crucial  incision.  A.s  soon  as  the  discharge 
hag  ceased,  the  sponges  or  gauze  are  withdrawn,  the  parts 
cleaned,  th<  extremities  of  the  tegumentary  wound  closed 


CLOSURE  OF  AS  ARTIFICIAL  ANUS. 


401 


with  sutures,  and  the  edges  of  the  opening  in  the  intestine 
made  fast  to  the  skin  with  a  few  sutures  of  fine  silk. 


CLOSURE  OF  AN  ARTIFICIAL  ANUS   OR  FECAL 
FISTULA. 

If  the  opening  in  the  gut  is  large,  the  remaining  part 
of  the  intestinal  wall  is  pressed  forward  into  it  and  forms 
a  sort  of  valve  or  spur,  which  prevents  more  or  less  com- 
pletely the  descending  current  of  feces  from  entering  the 
lower  segment  of  the  bowel. 

If  this  spur  were  absent  the  fistula  might  close  sponta- 
neously, and  to  accomplish  its  removal  Dupuytren's  enter- 
otome  was  formerly  introduced  through  the  opening  and 

Fig.  196. 


Dupuytren's  enterotome. 

clamped  upon  the  spur,  which  was  thus  cut  through  by 
four  or  five  days  of  continued  pressure. 

Immediately  before  undertaking  any  operation  the 
lumen  of  the  gut  above  and  below  the  fistula  is  plugged 
by  a  sponge  tied  to  a  string  which  serves  to  withdraw  the 
sponge  when  all  is  ready  to  close  the  intestinal  opening. 
The  interior  of  the  gut  is  then  irrigated  clean  and  the  skin 
surrounding  the  fistula  thoroughly  scrubbed  and  washed 
with  bichloride  solution. 

In  most  cases  the  fistulous  tract  between  the  intestine 
and  skin  is  lined  with  mucous  membrane,  and  if  the  spur 
is  slight  or  absent;  an  attempt  to  close  the  fistula  should 
26 


402   ABDOMINAL    WALL.  STOMACH,  AND  INTESTINES. 

first  be  made  by  separating  the  mucous  membrane  at  its 
junction  with  the  skin,  and  after  removing  the  sponge 
plugs,  inverting  it.  and  uniting  the  freshened  surfaces 
with  tine  catgut.  Over  this  the  pared  edges  of  the  ab- 
dominal opening  are  sutured  with  tine  silk,  aided,  if 
necessary  at  the  sides,  by  liberating  incisions  through 
the  skin  and  fascia. 

If  this  fails  or  a  more  elaborate  operation  seems  neces- 
sary, an  incision  two  or  three  inches  long  is  carried  across 
the  fistula  in  any  suitable  direction,  and  layer  by  layer 
down  to  the  peritoneum.  This  is  opened  at  one  ex- 
tremity of  the  incision  and  a  finger  inserted  into  the 
abdomen  to  determine  the  limit  of  the  adhesions;  and  as 
soon  as  possible  the  peritoneal  cavity  is  walled  off  by 
sponges  packed  in  around  the  open  intestine,  which  has 
been  previously  plugged  above  and  below  as  already  de- 
scribed. Cutting  on  the  linger  as  a  guide,  the  gut  is 
separated  from  its  parietal  attachment  around  the  fistula, 
and  if  possible  drawn  out  of  the  abdomen  and  constricted 
above  and  below  the  pings  by  gauze  bands  passed  through 
the  mesentery. 

The  sponge  plugs  are  withdrawn,  the  interior  of  the  gut 
irrigated,  and,  if  the  opening  Is  -mall,  its  edges  are  fresh- 
ened and  inverted,  and  the  peritoneal  coat  drawn  together 
over  it  with  Lembert  sutures.  The  constricting  bands 
are  removed  and  the  gut  returned  to  the  abdomen,  which 
i-  closed  in  the  usual  way.  If  the  opening  is  extensive, 
the  damaged  segment  of  the  gut  is  excised  and  circular 
enterorrhaphy  or  lateral  anastomosis  done. 

The  fistulous  tract  is  then  dissected  out  of  tin-  ab- 
dominal wall  and  the  wound  closed. 

THE   OPERATION  FOR  THE  REMOVAL  OF   THE   VER 

MIFORM  APPENDIX. 

[n  a  case  of  appendicitis  operated  on   in  the  period  of 

quiescence,  an  incision  three  or  four  inches  long  is  made 

at  the  outer  border  of  the  right  rectus  muscle,  with  its 

.•enter  about  on  the  line  joining  the  umbilicus  and  the  an- 
terior  superior  -pine  of  the  right    ilium.      The  lower  ex- 


REMOVAL   OF  THE    VERMIFORM  APPENDIX.     403 

treinity  of  the  incision  should  not  reach  the  deep  epigastric 
artery,  the  course  of  which  is  indicated  by  a  line  drawn 
from  the  femoral  ring  to  the  umbilicus. 

The  tissues  are  divided  layer  by  layer,  all  bleeding 
stopped,  and  the  peritoneum  pinched  up  and  opened. 
Adhesions  arc  separated  by  the  finger-nail  or  blunt- 
pointed  scissors,  and  it'  necessary  divided  between  ;i 
double  ligature.  The  anterior  longitudinal  band  of  the 
colon  is  traced  to  its  origin  at  the  root  of  the  appendix. 
After  walling-  off  the  surrounding  peritoneum  with  a 
sponge  packing,  the  appendix  is  isolated  and  a  double 
ligature  of  stout  catgut  passed  by  an  aneurism  needle 
through  its  mesentery  close  to  the  root  of  the  appendix. 
The  needle  is  withdrawn,  the  loop  of  the  ligature  cut, 
and  on  one  side  the  mesentery,  which  usually  contains  a 
single  artery,  is  tied  off,  and  on  the  other  side  the  ap- 
pendix is  ligated  as  close  to  the  caecum  as  possible.  The 
mesentery  and  appendix  are  then  excised  close  to  the  dis- 
tal side  of  the  ligatures.  The  csecal  stump  of  the  appen- 
dix is  held  isolated  and  in  view  till  thoroughly  cauterized 
with  the  Paquelin  or  pure  carbolic  acid,  but  in  using  the 
latter  care  must  be  taken  to  prevent  its  spreading  to  the 
neighboring  surface  of  the  csecum. 

The  sponge  protectives  are  then  removed,  the  parts  al- 
lowed to  assume  their  normal  position,  and  one  end  of  a 
strand  of  iodoform  gauze  is  placed  in  contact  with  the 
cauterized  stump  and  the  other  end  brought  out  of  the 
abdominal  wound. 

The  peritoneum  and  overlying  parts  are  closed  in  the 
usual  way  except  where  the  gauze  drain  emerges.  Here 
a  suture  of  silk  is  passed  through  the  entire  thickness  of 
the  abdominal  wall,  including  the  peritoneum,  and  left  un- 
tied till  the  drain  is  removed  forty-eight  hours  later.  This 
must  be  done  with  every  antiseptic  precaution,  and  only 
done  if  no  inflammatory  symptoms  exist.  The  dressings 
then  applied  are  left  undisturbed  about  ten  days. 

Instead  of  ligating  the  appendix  as  described  it  may  be 
inserted  into  the  colon  as  follows  :  A  fine  silk  suture  is 
passed  circularly  a  little  beyond  the  base  of  the  appendix, 


404  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

in  and  out  through  the  serous  and  muscular  layers  of  the 
colon,  like  a  purse-string.  The  appendix  is  cut  off  about 
half  an  inch  from  its  base,  and  a  silk  suture  tied  across  the 
cut  end  at  its  center.  Against  this  suture  is  en<rao;ed  the 
notched  end  of  a  probe  or  a  match,  and  by  pressure  with 
the  probe  the  stump  can  be  easily  inverted  ;  the  probe  is 
withdrawn  as  the  circular  suture  is  drawn  tight  and  tied. 

Dr.  McBurney '  has  given  us  a  method  which,  while 
more  difficult  of  execution,  obviates  the  risk  of  hernia  : 
An  incision,  oblique  downward  and  inward,  is  made  about 
an  inch  and  a-half  to  the  inner  side  of  the  anterior  su- 
perior spine  of  the  ilium.  The  aponeurosis  of  the  exter- 
nal oblique  is  split  in  the  direction  of  its  fibers,  the  sheath 
of  the  internal  oblique  divided  transversely,  and  its  fibers 
and  those  of  the  transversalis  carefully  separated  without 
cutting  from  the  ileum  to  the  rectus.  The  fascia  and 
peritoneum  are  divided,  the  sides  of  the  opening  held 
apart  with  broad  retractors,  and  the  appendix  removed  as 
above  described. 

Operation  during  the  Period  of  Inflammation. — If  a  dis- 
tinct tumefaction  is  perceptible,  with  a  probability  of  the 
presence  of  pus,  the  incision  is  made  about  four  inches 
long  parallel  to  the  outer  border  of  the  right  rectus  over 
the  most  prominent  part  of  the  tumor,  or,  if  there  is  no 
tumefaction,  over  the  most  tender  spot,  and  the  appendix 
removed  as  already  described.  If  the  peritoneum  is 
reached  without  a  previous  escape  of  pus  it  is  opened  at 
;in  angle  of  the  incision,  preferably  the  upper,  and  a  fin- 
ger inserted  to  determine  the  position  of  the  mass  and  the 
limit  of  the  adhesions.  Through  this  exploratory  open- 
ing :i  sponge  packing  is  inserted  as  soon  as  possible,  and 
the  inflamed  area  walled  off  from  the  rest  of  the  ab- 
dominal cavity. 

The  peritoneal  opening  is  then  enlarged  and  the  dissec- 
tion carried  into  the  densest  pari  of  the  tumefaction. 
Fresh  adhesions  are  besl  separated  by  tearing  with  the 
finger-nail,  but  the  possibilit v  of  lacerating  the  bowel  must 

not  be  forgotten,  and,  if  accessary,  the  blunt-pointed  scis- 

1  Annul-  of  Surgery,  L894. 


STOMACH.  405 

eors  and  double  catgut  ligature  arc  used  for  the  strongest 
adhesions,  especially  those  involving  omentum.  The 
moment   pus  appears  the  manipulations    are    suspended, 

while  it  is  encouraged  to  How  out  or  else  sponged  rapidly 
away  without  disturbing  the  relations  of  the  surrounding 
parts. 

The  opening  in  the  abscess  cavity  is  cautiously  enlarged 
without  getting  beyond  the  adhesions  which  protect  the 
rest  of  the  peritoneal  cavity.  If  such  an  accident  does 
occur  a  clean  sponge  is  immediately  packed  into  the  rent 
and  the  dissection  continued  until  the  appendix  is  found. 
It  is  excised  and  the  stump  cauterized  and  tied  as  above 
described. 

An  abscess  cavity  in  the  pelvis  may  sometimes  need  to 
be  drained  by  a  tube  passed  through  a  counter-opening  in 
the  rectum  and  a  cavity  in  the  loin  by  a  tube  passed 
through  the  back  just  above  the  iliac  crest. 

After  every  trace  of  pus  has  been  sponged  or  washed 
away  one  or  more  tubes  should  extend  from  the  abdominal 
wound  into  every  recess  of  the  suppurating  region  and 
each  surrounded  with  an  iodoform-gauze  packing.  The 
sponge  protectives  are  then  removed  and  their  places  sup- 
plied by  strips  of  iodoform  gauze,  the  upper  and  lower 
angles  of  the  wound  arc  sutured  in  the  usual  way,  and  a 
strip  of  iodoform  gauze  placed  over  the  intestines  beneath 
them.  The  ends  of  all  the  strips  of  gauze  are  brought  out 
at  the  center  of  the  wound  and  counted. 

After  the  first  twelve  to  twenty-four  hours  the  dressings 
will  probably  be  saturated  with  the  blood-stained  serous 
discharge  and  need  changing,  which  then  and  aftenvard 
must  be  done  with  every  antiseptic  precaution.  The  gauze 
directly  beneath  the  suture  line  can  probably  be  removed 
in  twenty-four  to  forty-eight  hours,  but  it  will  require  a 
vigorous  pull. 

STOMACH. 

Anatomy. — The  cardiac  orifice  lies  about  one  inch  to  the 
left  of  the  sternum  beneath  the  seventh  left  costal  cartilage. 
The  pyloric  orifice  in  the  empty  stomach  lies  in  the  median 


406  ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 

line  or  close  to  the  right  of  it  and  two  or  three  inches  be- 
low the  end  of  the  gladiolus,  and  is  in  relation  with  the 
neck  of  the  gall-bladder,  the  portal  vein,  the  gastro- 
duodenalis,  and  right  gastro-epiploica  arteries,  the  pan- 
creas, and  the  splenic  vein.  The  lesser  curvature  is  con- 
nected with  the  transverse  fissure  of  the  liver  by  the  lesser 
omentum,  which  contains  from  left  to  right  the  gastric, 
pyloric,  and  hepatic  arteries,  the  portal  vein,  and  common 
bile  duct.  The  great  omentum  passes  downward  from 
the  greater  curvature,  on  which  lie  the  right  and  left 
gastro-epiploica  arteries,  across  the  colon,  to  which  the 
anterior  layer  is  generally  adherent,  the  posterior  always. 
The  transverse  mesocolon  is  near  the  posterior  surface  of 
the  stomach.  The  left  lobe  of  the  liver  descends  in  front 
of  the  stomach  a  variable  distance,  generally  not  below 
the  ninth  left  costal  cartilage.  When  the  stomach  is  dis- 
tended, it  is  in  contact  with  the  anterior  abdominal  wall 
over  quite  a  large  area  below  the  left  lobe  of  the  liver; 
when  it  is  empty,  this  area  of  contact  becomes  very  small, 
and  lies  between  the  left  lobe  of  the  liver  and  a  transverse 
line  drawn  at  the  level  of  the  anterior  end  of  the  ninth 
rib.  The  guide  to  this  line,  as  Tillaux  has  shown,  is  the 
anterior  end  of  the  tenth  rib,  which  can  be  readily  felt 
projecting  beyond  the  border  of  the  cartilages  of  the  false 
ribs,  andean  be  made  to  yield  a  sort  of  friction  sound  by 
rubbing  it  against  the  ninth.  Sedillot  claimed  that  when 
the  stomach  was  empty,  it  was  nowhere  in  contact  with 
the  anterior  abdominal  wall,  being  separated  from  it  by 
the  liver  and  transverse  colon,  and  recommended  that  it 
should  be  approached  by  a  crucial  incision  through  the 
left  rectus  muscle  two  or  three  inches  below  the  xiphoid 
appendix  of  the  sternum.  lie  passed  his  linger  along  t lie 
border  of  the  left  lobe  of  the  liver  t<»  the  diaphragm,  en- 
countered the  stomach  there,  seized  it  with  pronged  forceps 
introduced  along  the  linger,  and  drew  it  up  to  the  incision 
while  pressing  the  colon  downward.  Although,  as  stated, 
more  recent  investigations  have  shown  that  the  normal 
stomach  when  empty  i-  still  in  contact  with  the  anterior 
abdominal  wall,  these  directions  for    finding   the   stomach 


GASTROSTOMY 


401 


may  be  useful  in  cases  where  it  lias  been  drawn  back  and 
bound  down  to  the  posterior  wall  by  inflammatory  adhe- 
sions or  neoplasms. 

GASTROSTOMY. 

It  consists  in  the  establishment  of  a  fistula  through  the 
walls  of  the  stomach  and  abdomen. 

Operation. — An  incision  one  and  a-half  or  two  inches 
long  is  made  parallel  to  and  a  ringer-breadth  from  the  free 
border  of  the  left  costal  cartilage,  ending  below  opposite 
the  end  of  the  tenth  rib.  The  tissues  are  divided  layer 
by  layer,  the  peritoneum  pinched  up  and  opened.     When 


Anatomical  relations  of  the  stomach  with  reference  to  gastrostomy. 

the  stricture  is  close  the  stomach  and  intestines  are  usually 
empty  and  the  abdomen  deeply  sunken  by  atmospheric 
pressure.  In  such  cases,  when  each  successive  layer  is 
divided  it  rises  from  the  underlying  mass,  and  when  the 
peritoneum  is  opened  the  air  rushes  in  and  the  abdominal 
wall  rises  away  from  the  stomach  and  becomes  level  with 
the  sternum  and  ribs.  The  stomach  is  recognized  just 
below  the  left  lobe  of  the  liver  by  its  white  color,  smooth 
surface,  and  the  arrangement  of  its  arteries.  If  it  does  not 
present  in  the  wound  the  transverse  colon  and  omentum 
arc  pressed  down,  the  ringers  passed  up  under  the  left  lobe 
of  the  liver  and  to  the  left  close  to  the  diaphragm  and 
vertebral  column,  and  the  lesser  curvature  sought  for. 
When  found  a  fold  of  the  stomach   is  picked  up  by  the 


1:08  ABDOMINAL  WALL,  STOMACH.  AND  INTESTINES. 

fingers  and  a  spot  fixed  upon  which  avoids  too  much  trac- 
tion and  is  suitable  for  a  fistula.  The  method  now  in  favor 
in  gastrostomy  is  to  stitch  the  parietal  peritoneum  to  the 
skin  all  around  the  incision,  and  then  to  fasten  the  un- 
opened stomach  in  the  wound  by  several  sutures  which 
traverse  its  muscular  coat  but  do  not  enter  its  cavity,  and 
whose  deeper  ends  then  transfix  the  abdominal  wall.  This 
gives  a  broad  surface  of  contact  between  the  peritoneum 
of  the  stomach  and  that  of  the  abdominal  wall,  and  favors 


Fig.   198. 


Kader's  method  of  gastrostomy.     First  and  sec 1  rows  of  sutures. 

their  prompt  union.  The  protruding  portion  of  the 
stomach  may  also  be  transfixed  with  two  long  pins  which 
nst  upon  the  skin  and  prevent  strain  on  the  sutures.  The 
opening  of  the  stomach  is  delayed  as  long  as  possible,  from 
one  to  eight  days.  If  necessary,  food  can  be  introduced 
by  puncturing  with  an  aspirating  needle. 

Wit/el  '  divides  the  skin  parallel  to  the  ribs  and  a 
finger's  breadth  distant,  then  the  rectus  niusele  longitudi- 
nally, and  the  t ransversalis  horizontally.  Next  the  an- 
terior wall  of  the  stomach    is  drawn    into   the   abdominal 

'Centralb.  f.  Chir.,  1891,  p.  601. 


GASTROSTOMY. 


m 


wound  sufficiently  to  permit  of  its  being  folded  length- 
wise and  sutured  over  a  rubber  tube,  which  at  one  ex- 
tremity enters  the  viscus  and  at  the  other  is  brought  out 
of  the  opening  in  the  skin.  The  stomach  is  then  fas- 
tened in  the  wound  in  the  ordinary  way  by  a  row  of 
sutures  around  the  folds  enclosing  the  tube,  and  over  the 
latter  the  skin  is  united,  leaving  only  a  small  hole  for  the 
exit  of  the  tube.     This   is   intended   to    make  the  fistula 

Fig.  199. 


Kader's  method.     Final  condition. 


communicate  less  directly  with  the  surface  of  the  body, 
and  thus  insure  better  retention  of  the  gastric  contents. 
It  is  important  that  the  tube  should  fill  and  even  distend 
the  orifice  by  which  it  enters  the  stomach. 

Kader's  Method.1  (Figs.  198,  199.)— This  is  claimed  to 
be  more  generally  applicable  than  Witzel's,  and  certainly 
it  gives  most  satisfactory  control  against  leakage.  In- 
cision as  in  AVitzel's.     The  sides  of  the  opening  are  held 

1  K:\der,  Centralblatt  fur  Chir.,  1896,  p.  665. 


4ln  ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 


Fig.  200. 


apart,  and  a  small  fold  of  the  stomach  drawn  out  through 
it  and  fixed  with  hooks  or  two  stout  silk  sutures.  A 
small  opening  is  made  in  it,  and  through  this  a  rubber 
tube  as  large  as  a  lead  pencil  is  introduced  for  about  two 
inches  and  fixed  by  a  catgut  suture  at  the  opening.  On 
each  side  of  the  tube  at  half-inch  intervals  are  placed  two 
silk  Lembert  sutures  in  such  manner  that  they  appose 
serous  surfaces  one  centimeter  wide  and  create  a  ridge  on 
the  inner  surface  of  the  stomach.  This  ridge  is  then 
heightened  and  the  apposed  serous  surface  increased  by  a 
second,  parallel,  row  of  sutures.     (Fig.  198.) 

Fixation  sutures,  to  hold  the  stomach  against  the  ab- 
dominal wall,  are  then  passed  at  the 
ends  through  the  muscularis  of  the 
stomach  and  the  parietal  peritoneum 
and  adjoining  fascia,  and  supported  br- 
others along  the  sides  so  as  to  narrow 
the  opening  rather  closely  about  the 
tube.  The  resultant  condition  is  shown 
in  Fig.   199. 

After  healing  is  complete  the  tube 
is  withdrawn  and  is  reinserted  only 
for  the  introduction  of  food.  Mean- 
while the  lateral  pressure  of  the  con- 
tents of  the  stomach  upon  the  project- 
ing fold  prevents  leakage.  E.  'I.  Senn 
reports  good  results  in  respect  of  absence  of  leakage  from 
a  method  by  which  he  creates  a  mamelon  upon  the  surface 
of  the  stomach  by  Lembert  sutures  at  its  base.  At  the 
apes  of  this  mamelon  he  makes  the  opening  and  then  in- 
verts it  about  half  an  inch,  securing  the  inversion  by  a 
few  sutures. 

Leakage  from  a  straight  fistula  of  this  organ  can  be 
controlled  to  a  certain  extent  by  a  mechanical  device  con- 
sisting of  two    hollow  rubber  disks  closely  joined  at   their 

centers  by  a  hollow  rubber  cylinder  communicating  with 

each.  (Fig.  200.)  The  lower  disk  is  passed  through  the 
fistula  into  the  stomach,  ami  both  disks  are  then  distended 
with  air  or  water  and  thu-  made  to  block  the  opening. 


Ping  of  two  hollow  ml 
ber   ili>k~   for   closing 
gastrostomy  fistula. 


CASTnOTOMY.  411 

In  cases  where  the  stomach  need  not  he  opened  for 
some  days  it  is  sufficient,  after  uniting  the  skin  and  pari- 
etal peritoneum,  to  pass  a  couple  of  harelip  pins  through 
its  outer  coats,  enclosing  a  portion  of  the  stomach  wall 
about  three-quarters  of  an  inch  square.  The  pins  are 
simply  laid  upon  the  skin  transversely  to  the  abdominal 
wound,  and  the  opening  made  in  the  center  of  the  square 
they  enclose  after  adhesions  have  formed. 

A  crucial  abdominal  incision  below  the  ensiform  proc- 
ess was  used  by  Scdillot.  Others  have  employed  a 
vertical  incision  in  the  linea  alba,  in  the  substance  of 
the  outer  part  of  the  left  rectus,  or  in  the  left  linea  semi- 
lunaris. 

Halm  opened  and  fixed  the  stomach  in  the  eighth  in- 
tercostal space  after  first  entering  the  abdomen  by  an  in- 
cision parallel  with  the  lowest  rib.1 

GASTROTOMY. 

This  is  the  operation  in  which  the  surgeon  opens  the 
stomach  and  then  closes  the  opening  at  the  conclusion  of 
the  operation. 

Operation. — If  it  is  performed  for  the  removal  of  a  for- 
eign body  which  can  be  felt  through  the  anterior  abdom- 
inal  wall,  the  incision,  at  least  two  inches  long,  is  made 
over  the  tumefaction  and  in  the  direction  which  inflicts  the 
least  damage  on  the  intervening  tissues.  Otherwise  the 
incision  is  made  in  the  median  line  just  below  the  ensiform 
process  or  parallel  to  the  left  costal  cartilages,  as  in  gas- 
trostomy. The  tissues  are  divided  layer  by  layer,  the 
peritoneum  opened,  and  one  finger  introduced  to  locate  the 
foreign  bod  v. 

After  protecting  the  surrounding  peritoneal  surface  by 
gauze  pads  or  sponges,  the  part  of  the  stomach  wall  to  be 
opened  is  carefully  drawn  into  the  abdominal  wound  and 
held  there  by  a  couple  of  temporary  retention  sutures 
passed  through  the  peritoneal  and  muscular  coats  on  each 
side  of  the  intended  opening,  which  is  then  made  parallel 
to  the  course  of  the  blood  vessels,  that  is,  transversely  to 
iCentraJb.  f.  Chir.,  1890,  p.  193. 


412  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

the  lon»r  axis  of  the  stomach.  The  foreign  body  is  re- 
moved gently,  with  due  regard  for  its  sharp  points,  or  the 
ulceration  or  sloughing  which  may  exist,  and  if  necessary 
the  stomach  is  washed  out.  There  must  be  as  little  spong- 
ing or  irritation  of  its  interior  as  possible. 

The  incision  in  the  stomach  is  closed  by  a  continuous 
silk  suture  of  the  mucous  membrane,  then  by  a  row  of 
Lembert  sutures,  which  are  reinforced  by  a  continuous 
silk  suture  through  the  peritoneal  coat.  After  the  region 
of  the  wound  has  been  made  dry  and  clean,  the  temporary 
retention  sutures  are  withdrawn,  the  protecting  sponges 
are  removed  from  the  abdominal  cavity  and  the  parietal 
wound  closed  and  dressed  as  described  for  an  aseptic  lapa- 
rotomy. 

Greig  Smith  does  not  suture  the  mucous  membrane  of 
the  stomach,  but  closes  the  wound  by  a  row  of  Lembert 
sutures  reinforced  by  a  continuous  or  interrupted  suture  of 
the  peritoneal  coat.  The  continuous  suture  prevents  gap- 
ing of  the  wound  during  expansion  of  the  stomach. 

By  gastrotomy  Bull '  and  Richardson  successfully  re- 
moved foreign  bodies  impacted  in  the  oesophagus  near  the 
cardiac  orifice  of  the  stomach.  Richardson  demonstrated 
that  the  lower  three  inches  of  the  oesophagus  are  thus 
accessible  by  an  incision  parallel  to  the  left  costal  carti- 
lages, through  which  he  introduced  his  whole  hand  into  the 
stomach  and  extracted  a  set  of  false  teeth  from  the  lower 
end  of  the  gullet." 

Gastrotomy  for  Benign  Stenosis  of  the  Pyloric  or  Cardiac 
Orifices.  (Sometimes  called  Loretta's  operation.) — Before 
the  operation  the  stomach  is  washed  out  repeatedly  with 
an  alkaline  solution.  The  pylorus  is  reached  by  an  in- 
cision four  or  five  inches  long,  usually  in  the  linea  alba 
between  the  xiphoid  appendix  and  the  umbilicus ;  or  else 
approximately  parallel  to  and  about  an  inch  from  the 
right  costal  cartilages,  starting  an  inch  below  and  an  inch 
and  a-half  to  the  left  of  the  xiphoid  appendix  and  ter- 
minating near  the   Level  of  the  cartilage  of  the  ninth  rib. 

1  New  V<»rk  Medical  Journal,  October  -'.>,  1887. 
1  Lancet,  October  8,  1887. 


GASTROTOMY 


413 


The  tissues  are  divided  layer  by  layer,  and  the  peri- 
toneum opened.  The  surrounding  peritoneal  surface  is 
protected  and  held  out  of  the  way  in  the  usual  manner, 
while  the  pylorus  is  sought  for,  and  such  adhesions  as 
may  exist  are  divided  between  double  catgut  ligatures. 
The  anterior  wall  of  the  stomach  is  drawn  into  the 
abdominal  wound,  and  after  again  carefully  protecting 
the  surrounding  peritoneal  surface  is  incised  transversely 
for  from  one  to  three  inches  between  its  two  curvatures 
near  the  pylorus,  but  outside  of  the  inflammatory  zone  ad- 
joining it.  Guided  by  two  fingers  grasping  the  pylorus 
externally,  the  forefinger  of  the  right  hand  is  passed 
through   the  stomach   into  the  pyloric  orifice.     This  may 

Fig.  201. 


B  A 

Pyloroplasty.     A.  The  incision,  A,  B,  alone  the  contracted  pylorus.    B.  (Insure 

of  this  wound  transversely.     The  point  A  united  to  B. 


require  considerable  force,  or  the  orifice  may  have  be- 
come so  contracted  that  preliminary  dilatation  with  some 
small  instrument  is  necessary.  McBurney  used  a  small 
bivalve  anal  speculum.  Dilatation  is  continued  till  it  is 
felt  that  any  further  stretching  would  threaten  a  rupture 
of  the  viscus.  The  wound  in  the  stomach  is  then  sutured 
as  described  in  gastrotomy  for  a  foreign  body,  and,  after 
cleansing  and  drying  the  field  of  operation  and  removing 
the  protective  pads  or  sponges,  the  parietal  wound  is 
closed  as  usual. 

To  reach  the  cardiac  orifice,  the  abdominal  incision  is 
made  obliquely  from  a  point  just  below  the  ensiform  proc- 


414  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

ess  parallel  to  and  about  one  inch  from  the  left  costal 
curtilages.  The  anterior  wall  of  the  stomach  is  opened 
l)v  a  longitudinal  incision  made  between  the  two  curva- 
tures and  as  near  the  cardiac  end  as  possible. 

Pyloroplasty. — Instead  of  performing  gastrotomy  and 
divulsion  of  the  pylorus,  the  stricture  can  be  relieved  by 
longitudinal  division  followed  by  transverse  reunion.  (Fig. 
201.)  The  median  or  right  oblique  abdominal  incision  is 
employed,  any  adhesions  about  the  pylorus  are  separated, 
and  after  carefully  walling  off  the  surrounding  peritoneum 
with  sponges  an  incision  opening  the  lumen  of  the  viscera 
about  an  inch  and  a-half  long  is  carried  across  the  py- 
loric ring,  through  the  neighboring  anterior  wall  of  the 
stomach  and  first  part  of  the  duodenum.  The  opposite 
extremities  of  this  incision  are  then  united  to  each  other 
to  form  the  center  of  an  apparently  transverse  wound, 
which  is  closed  by  the  Czerny-Lenibert  suture.  The 
parietal  incision  is  then  closed  tight  in  the  usual  way. 

GASTRORRHAPHY. 

This  is  the  operation  for  closing  a  wound  or  opening 
in  the  stomach,  or  to  diminish  its  capacity  by  creating  a 
permanent  longitudinal  fold  in  its  anterior  wall  (Gastro- 
plication ). 

Operation. — If  it  is  undertaken  to  close  a  gastric  fistula, 
the  interior  of  the  stomach,  the  fistulous  tract,  and  sur- 
rounding skin  are  made  as  clean  as  possible.  A  sponge 
tied  to  a  string  is  pushed  through  the  fistula  and  held  by 
an  assistant  against  its  interior  orifice.  An  incision  is 
then  made  not  less  than  two  inches  long  in  any  conve- 
nient direction  across  the  fistula  and  through  the  abdom- 
inal wall,  layer  by  layer,  until  the  peritoneum  is  reached. 
This  is  opened  ;it  line  extremity  of  the  wound  and  a  fin- 
ger inserted  to  determine  the  limit  of  the  adhesions.  <  >n 
this  finger  as  a  director,  the  peritonea]  incision  is  enlarged 
around  the  fistula,  which  is  then  surrounded  l>y  sponges 
packed  into  the  abdominal    cavity.       The    Liberated    -loin- 

aeh  i-  drawn  into  the  abdominal  wound,  and  the  margins 
of  the  opening  in  the  stomach   freshened  and  closed  as 


GASTBOBRHAPHY.  415 

described  in  gastrotomy,  after  withdrawing   the    sponge 

from  the  interior  of  the  stomach. 

The  fistulous  tract  is  excised  from  the  abdominal  wall, 
and,  after  the  operation  area  has  been  thoroughly  cleansed 
and  dried,  the  wound  is  closed  in  the  usual  way  with  or 
without  a  gauze  packing. 

If  the  operation  is  undertaken  for  a  perforating  wound 
or  ulcer  of  the  stomach,  immediately  after  opening  the 
peritoneal  cavity  by  an  ample  incision,  either  median,  just 
below  the  ensiform  process,  or  parallel  to  the  left  costal 
cartilages,  all  extra vasated  material  must  be  sponged  away 
or  irrigated  out  of  the  peritoneal  cavity  with  boiled  water, 
and  the  opening  in  the  stomach  closed  as  described  in 
gastrotomy.  The  operation  area  is  walled  around  by 
sponges  or  pads  and  a  sponge  is  then  passed  into  the  lesser 
peritoneal  sac  through  a  small  opening  made  in  the  great 
omentum,  between  the  stomach  and  transverse  colon.  If 
the  lesser  sac  is  found  infected,  or  there  is  even  a  suspicion 
of  an  opening  on  the  posterior  surface  of  the  stomach,  this 
opening  must  be  sought  for  and  closed.  If  it  cannot  be 
reached  and  sutured  through  the  great  omentum  (between 
the  stomach  and  transverse  colon),  rather  than  leave  it 
unclosed,  Greig  Smith  advises  an  incision  in  the  anterior 
wall  of  the  stomach,  through  which  the  opening  in  the  pos- 
terior wall  may  be  closed  from  within.  After  everything 
has  been  made  as  clean  as  possible,  and  all  sponges  re- 
moved from  the  abdominal  cavity,  tubes  surrounded  by  a 
plentiful  gauze  packing  should  extend  into  all  the  infected 
regions  in  the  greater  and  lesser  peritoneal  sacs  and  con- 
nect them  with  the  skin  surface. 

The  parietal  wound  is  then  partially  closed  and  dressed 
antiseptically. 

Gastroplication. — To  diminish  the  capacity  of  the 
stomach,  it  is  exposed  by  one  of  the  incisions  above  de- 
scribed and  its  anterior  wall  drawn  well  out  through  the 
wound.  Two  points,  several  inches  apart  according  to  the 
size  to  be  given  to  the  tuck,  are  caught  up  and,  the  inter- 
mediate portion  being  depressed  in  a  longitudinal  fold,  are 
fastened  together  by  a  broad  Lembert  silk  suture,   Similar 


416  ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 

sutures  are  placed  on  each  side  at  half-inch  intervals  to 
lengthen  and  maintain  the  fold.  The  stomach  is  then 
dropped  back  and  the  parietal  opening  closed. 

PYLORECTOMY. 

The  stomach  should  be  repeatedly  washed  previously 
and  should  be  empty  at  the  time  of  operation.  The  ab- 
dominal incision  is  made  in  the  linea  alba  between  the 
ensiform  process  and  umbilicus,  or  over  the  most  promi- 
nent part  of  the  tumor,  and  more  or  less  transversely,  from 
just  to  the  left  of  the  median  line  in  the  direction  of  the 
free  border  of  the  right  costal  cartilages  and  not  less  than 
an  inch  from  them.  Other  forms  of  incision  that  have 
been  employed  are  longitudinal  at  the  outer  border  of  the 
right  reetus,  transverse  over  the  tumor,  or  crucial.  At 
first  the  incision  is  only  made  large  enough  for  exploration; 
if  then  the  operation  is  deemed  feasible,  it  is  enlarged  till 
it  is  from  three  to  five  inches  long. 

Sponges  are  packed  into  the  abdomen  around  the  tumor, 
which  is  drawn  as  much  as  possible  into  the  abdominal 
wound.  The  great  and  small  omenta  are  cut  close  to  the 
greater  and  less  curvatures  of  the  stomach,  after  first  se- 
curing the  vessels  between  double  ligatures,  till  the  point 
toward  the  left  is  reached  where  the  stomach  wall  is  to  be 
divided.  Great  care  must  be  taken  not  to  wound  the 
portal  vein,  hepatic  artery,  or  common  bile  duct  which  lie 
behind  the  pylorus,  and  no  damage  must  be  done  to  the 
transverse  mesocolon.  If  the  disease  involves  this  struc- 
ture the  operation  should  be  abandoned. 

Fresh  sponges  are  now  packed  around  the  liberated 
pyloric  <nd  of  the  stomach,  and  the  growth,  with  a  margin 
of  healthy  tissue,  is  excised  with  scissors.  All  vessels  are 
secured  as  they  are  divided,  the  lumen  of  the  duodenum  is 
immediately  plugged  by  a  sponge,  and  after  removing  all 
extravasated  matter  and  renewing  the  sponge  packing 
around  the  field  of  operation,  the  large  opening  in  the 
stomach  ie  narrowed  on  the  side  of  the  less  curvature  by 
Czerny-Lemberl  sutures  till  the  opening  which  remains 
next  the  greater  curvature  approximates  the  size  of  the 


I'YLORECTOMY. 


417 


duodenum.  If  circumstances  require  the  implantation  of 
the  duodenum  near  the  less  curvature,  the  opening  in  the 
stomach  is  narrowed  below  or  on  both  sides  in  the  same 
way  (Fig.  202),  the  posterior  walls  of  the  stomach  and 
duodenum  at  their  respective  points  of  division  are  then 
approximated  and  the  margins  of  the  wounds  behind  are 
inverted  to  bring  the  posterior  peritoneal  surfaces  in 
contact. 

The  redundant  mucous  membrane  is  raised  at  its  cut 
edge  and  sutures  of  fine  silk  are  passed  beneath  it  from 
the  inside,  at  intervals  of  an  eighth  of  an  inch,  through 
the   muscular  and   peritoneal   coats  of   the   stomach  and 


Fig.  202. 


Pylorectomy.    Showing  method  of  narrowing  the  opening  iu  the  stomach. 

duodenum.  When  knotted  the  sutures  lie  beneath  the 
mucous  membrane,  which  can  be  closed  over  them  by  a 
continuous  or  interrupted  suture  (Fig.  203).  Only  about 
the  posterior  half  of  the  stomach  and  duodenum  can  be 
united  in  this  way. 

The  sponge  is  then  withdrawn  from  the  duodenum  and 
the  remainder  of  the  wound  is  closed  by  the  Czerny- 
Lembert  suture.  After  testing  the  suture  line  by  filling 
the  stomach  with  water,  the  operation  area  is  made  clean 
and  dry,  the  protective  sponge  packing  is  removed,  and 
the  abdominal  wound  is  closed  in  the  usual  way. 

Senn's  omental  graft  to  surround  the  suture  line  in  the 
viscera  might  be  useful. 

'J  7 


418   ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

In  extensive  resections  of  the  pylorus,  Billroth  and 
others  have  closed  the  resulting  wounds  in  the  stomach 
and  duodenum  by  Lembert  sutures  and  then  restored  the 
continuity  of  the  alimentary  canal  by  performing  a  gas- 
troenterostomy. 

On  account  of  the  high  mortality  of  pyloreetomy  for 
malignant  disease,  this  operation  is  now  rarely  done  ;  in 
general  it  may  be  stated  that  when  the  tumor  can  be  felt 

Fig.  203. 


Wolfler's  methods  of  uniting  the  wound  in  the  posterior  portion  of  the  stomach 
after  pyloreetomy.    The  shaded  lines  represent  tin-  mucosa. 

through  the  anterior  abdominal  wall,  it  is  scarcely  justifi- 
able to  attempt  its  removal. 

GASTROENTEROSTOMY. 

The  preliminary  washing  of  the  stomach  and  the  ab- 
dominal incision  are  the  same  as  for  pyloreetomy,  but  the 
abdomen  is  more  commonly  opened  in  the  median  line 
between  the  ensiform  process  and  the  umbilicus.  The 
firsl     loop  of    intestine    which    presents    is    grasped    and 

traced    upward    to    the    dnode n.       It    should    be    noted 

that  tins  part  of  the  gut  is  thicker,  of  greater  diameter, 
ami  more  vascular  than  thai  nearer  the  colon.  Czerny 
advisee  thai  the  origin  of  the  jejunum  be  sought  for  al 
<.nce  by  drawing  up  the  stomach,  great  omentum,  and 
transverse  colon,  and  following  back  the  transverse  meso- 
colon to  the  spine  ;  immediately  to  the  left  of  this  lies  the 


(i  A  STlin-KXTEIlOSTOMY. 


419 


end  of  the  duodenum.  A  portion  is  then  selected  as  near 
to  the  latter  as  will  permit  easy  coaptation  with  the  stom- 
ach, the  great  omentum  is  pushed  to  the  left  and  the  in- 
testine drawn  t<»  the  right  and  upward  over  the  colon. 
The  anterior  wall  of  the  stomach  near  the  greater  curva- 
ture and  the  selected  portion  of  intestine  are  drawn  as 
far  as  possible  into  the  abdominal  wound,  and  the  loop 
of  intestine  should  be  so  twisted  or  placed  that  at  the 


Fig.  204. 


Gaxtroenteroxtomy ;  diagram  to  show  the  method  of  anion  to  secure  similarity  in 
direction  of  the  peristalsis  of  the  stomach  and  intestine. 

conclusion  of  the  operation  the  direction  of  its  peristaltic 
wave  shall  not  be  opposite  to  that  of  the  stomach.  (Fig. 
204.) 

The  rest  of  the  abdominal  contents  are  Availed  off  by  a 
protective  sponge-packing,  and  the  selected  loop  of  intes- 
tine, squeezed  empty  by  the  lingers,  is  prevented  from 
tilling  by  a  rubber  or  gauze  band  passed  through  the 
mesentery  and  constricting  each  extremity  of  the  selected 
loop. 


420  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

A  continuous  silk  suture  through  the  peritoneal  and 
muscular  coats  is  then  made  to  unite  the  anterior  surface 
of  the  stomach  near  its  greater  curvature  to  the  posterior 
surface  of  the  intestine  a  little  to  the  mesenteric  side  of 
its  free  border,  for  about  four  inches. 

In  addition,  a  row  of  Lembert  sutures  may  be  placed 
anterior  to  the  continuous  suture,  although  this  is  not  ab- 
solutely necessary.  The  stomach  and  intestine  are  opened 
parallel  and  close  to  this  suture  line,  and  the  interior  of 
each  irrigated  clean — the  incisions  should  terminate  op- 
posite each  other  and  about  half  an  inch  short  of  the  ex- 
tremities of  the  suture  line.  Having  made  the  wounds 
and  their  surroundings  clean  and  dry,  the  adjoining  pos- 
terior margins  of  the  two  incisions  are  rapidly  sewn  to- 
gether by  a  continuous  suture  passed  through  the  entire 
thickness  of  the  walls,  and  this  suture  is  continued  as  far 
as  possible  around  each  angle  of  the  incision  and  along 
the  anterior  margins.  The  operation  is  then  completed 
by  a  row  of  Lembert  sutures  or  a  continuous  suture  ex- 
tending along  the  anterior  surface  from  one  end  to  the 
other  of  the  first  suture  line. 

The  constricting  hand  at  each  extremity  of  the  loop  of 
intestine  is  then  removed,  all  parts  are  made  clean  and 
dry,  the  surrounding  sponge-packing  is  taken  out,  the  vis- 
cera replaced,  and  the  abdominal  wound  closed  in  the 
usual  way. 

The  use  of  the  Murphy  button  is  preferred  by  many  to 
any  method  of  suturing. 

In  order  to  prevent  passage  of  the  bile  into  the  stom- 
ach through  the  opening  Braun  made  an  anastomosis  be- 
tween the  two  -ides  of  the  loop  of  jejunum,  and  Jaboulay 
made  one  between  the  duodenum  and  jejunum.  With 
tin'  same  object  Kocher  made  the  opening  into  the  intes- 
tine transverse  and  semilunar  in  shape  so  as  to  form 
:i  valve.  See  Tillmann's  Surgery,  Vol.  J 1 1.,  p.  98, 
Am.  Ed. 

In  postei'ior  g(wtroentei'OHtomy  the  opening  is  made  in 
the  posterior  wall  of  the  stomach  after  having  exposed  it 
l>\  tcarine  throned]  the  transverse  meso-colon  with  as  lit- 


HERNIOTOMY,  KELOTOMY.  421 

tie  injury  as  possible  to  its  vessels.     Tins   modification 

lias  many  advantages. 

Jejunostomy  for  inoperable  cancer  of  the  pylorus  has 
been  performed  a  few  times.  A  longitudinal  incision  is 
made  to  the  left  of  the  umbilicus,  the  omentum  and  trans- 
verse colon  pressed  upward,  and  a  loop  of  the  upper  por- 
tion of  the  jejunum  brought  into  the  wound  and  secured 
there  by  sutures  as  in  gastrostomy.  The  opening  made 
in  the  intestine  should  be  only  large  enough  to  admit  the 
tube  through  which  food  is  to  be  introduced. 

Maydl1  has  proposed  a  more  complicated  method,  as 
follows  : 

The  abdomen  is  opened  transversely  about  four  finger- 
breadths  below  the  ensiform  process,  a  loop  of  jejunum 
some  ten  or  twelve  inches  long  extracted,  and,  with  every 
antiseptic  precaution,  divided  transversely.  The  proxi- 
mal segment  is  then  connected  with  the  distal  a  few 
inches  below  the  point  of  division  by  an  anastomosis 
operation  to  preserve  the  biliary  and  pancreatic  secretions, 
and  the  distal  segment  fixed  in  the  abdominal  wound  as 
in  gastrostomy,  or  the  distal  segment  may  be  attached  to 
the  stomach,  thus  making  a  gastroenterostomy. 

HERNIOTOMY,   KELOTOMY. 

Under  this  head  are  to  be  described  the  operations  for 
the  relief  of  strangulated  inguinal,  femoral,  umbilical,  and 
obturator  hernias,  and  those  for  the  radical  cure  of  the  first 
three  varieties. 

It  has  been  well  said  that  there  is  no  operation  in  which 
the  unforeseen  has  a  larger  share  than  in  herniotomy,  none 
in  which  the  surgeon  is  called  upon  to  show  more  skill, 
sagacity,  and  decision.  The  causes  of  this  are  to  be  found 
in  the  absence  of  absolute  guides  to  the  hernial  sac,  the 
changes  in  the  sac  and  overlying  tissues  brought  about  by 
inflammation  or  time,  the  character  of  the  hernia — 
whether  composed  of  omentum,  intestine,  caecum,  or 
bladder,  and,  lastly,  the  difficulty  of  determining  not 
only  the  extent  of  the  injury  done  to  the  strangulated 
'Maydl:    Wien.  tued.  "Wochensch. ,  1892,  p.  697. 


422   ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 

tissues,  but  even,  in  some  cases,  the  route  taken  by  the 
hernia  in  its  descent.  It  is  desirable,  therefore,  that  the 
account  of  the  different  operations  should  be  preceded  by 
some  general  considerations  upon  these  subjects. 

General  Directions.  A.  Recognition  of  the  Sac  and 
BOWEL. — The  first  difficulty  encountered  in  the  course  of 
the  operation  is  that  of  recognizing  the  sac.  The  thick- 
ness of  the  connective  tissue  covering  it  varies  greatly  in 
different  cases  ;  each  layer  must  be  pinched  up  with  for- 
ceps, opened  with  the  knife  lying  upon  its  side,  as  in 
opening  the  sheath  of  an  artery,  then  raised  upon  the 
finger  or  a  director,  and  divided  to  the  full  extent  of  the 
cutaneous  incision,  after  having  been  carefully  scrutinized. 
Occasionally  a  cyst  containing  liquid  is  found  in  front  of 
the  hernia,  and  may  at  first  be  mistaken  for  it,  for  usually 
the  sac  contains  a  certain  amount  of  serum.  Careful  ex- 
amination of  the  tissues  before  division  is  absolutely  neces- 
sary, because  in  those  rare  cases  where  there  is  no  sac 
(hernia  of  the  cascum  or  of  the  bladder),  and  in  others 
where  it  is  quite  undistinguishable,  it  is  only  by  recogniz- 
ing the  muscular  coat  when  he  reaches  it,  that  the  surgeon 
avoids  opening  the  intestine  or  bladder  by  mistake.  As 
the  sac  is  approached,  each  layer  should  be  pinched  up  in 
a  narrow  fold  and  moved  gently  across  the  underlying 
parts  ;  if  a  smooth  globular  tumor  is  felt  below,  the  sur- 
geon makes  an  opening  in  the  fold,  confident  that  the  wall 
of  the  intestine  is  not  included  in  it  ;  but  if  he  is  unable  to 
pinch  up  the  fold,  or  if,  instead  of  the  sensation  of  a 
smooth  globular  mass,  he  gets  only  that  of  an  empty 
space,  he  examines  the  surface  again,  divides  any  fibrous 
bands  he  may  find  at  the  neck  of  the  hernia,  and  tries  to 
Introduce  his  finger  through  it  into  the  abdominal  cavity. 
If  he  succeeds,  he  knows  the  sac  has  been  opened  ;   if  lie 

does  not  succeed,  he  renews  the  examination  and  continues 
the  dissection. 

Maisonneuve  said    the   surgeon    may    know   he    has    not 

reached  the  intestine  bo  long  as  he  is  not  certain  of  having 

done  80  ;  but  tlii-  i~  not  true  of  all  cases;  the  intestine  is 
not   always   smooth    and    shining  ;   it   may  be   dark,   dull, 


HERNIOTOMY,   KELOTOMY.  423 

congested,  and  thickened,  and  in  bernia  of  the  caecum  or 
sigmoid  flexure  it  may  have  no  peritoneal  coat. 

When  the  hernia  is  small  and  recent  the  sac  is  bluish, 
and  can  be  pinched  up  between  the  thumb  and  finger,  so 
that  its  smooth  opposing  surfaces  can  he  felt  to  glide  upon 
one  another.  When  it  is  large  and  of  long  standing,  the 
sue  may  he  exceedingly  thin  and  unrecognizable,  or  very 
thick  and  adherent,  li'  small,  it  should  be  thoroughly 
isolated,  and  its  boundaries  everywhere  defined  ;  if  large 
and  adherent,  its  neck  alone  should  be  cleared. 

B.  Opening  of  the  Sac. — The  propriety  of  opening 
the  sac  used  to  be  a  subject  of  dispute.  The  only  objection 
to  it,  but  that  a  serious  one,  was  the  danger  of  thereby 
setting  nj)  peritonitis.  On  the  other  side  there  was  the 
danger  of  returning  the  hernia  into  the  abdomen  in  a 
gangrenous  condition,  or  unreduced  when  the  stricture 
was  formed  by  the  sae  itself.  Now,  however,  the  rule  is 
always  to  open  the  sac  with  every  antiseptic  precaution  and 
relieve  any  constriction  which  may  be  found  by  cutting- 
down  upon  it  layer  by  layer  from  without.  Then  either 
immediately  or  after  an  interval  a  radical  cure  is  performed. 

The  liquid  which  is  usually  contained  in  the  sac  may 
not  only  serve  to  call  attention  to  its  accidental  opening, 
but  may  also  be  taken  advantage  of  to  open  it  safely  when 
it  has  been  recognized.  It,  of  course,  collects  at  the  most 
dependent  point,  and  there  intervenes  between  the  sac  and 
the  bowel,  so  that  the  former  can  be  pinched  up  and 
opened  without  injury  to  the  latter.  When  this  is  not  the 
case,  the  surgeon  must  pinch  up  a  very  small  fold  of  the 
sac  wherever  he  can  do  so,  or  do  as  Mr.  Liston  did  in  a 
ease  where,  as  he  says,  "there  was  no  possibility  of  pinch- 
ing up  the  sac,  either  with  the  finger  or  forceps  ;  it  con- 
tained no  fluid,  and  was  impacted  most  firmly  with  bowel  ; 
very  luckily  the  membrane  was  there  ;  and,  observing  a 
pelleton  of  fat  underneath,  I  scratched  very  cautiously 
with  the  point  of  the  knife  in  the  unsupported  hand,  until 
a  trifling  puncture  was  made,  sufficient  to  admit  the  blunt 
point  of  a  narrow  bistoury."  l    The  opening  should  be  en- 

1  ( >p.  Surgery,  p.  4(52,  quoted  by  Jos.  Hell,  Manual  of  Surgical  Opera- 
tions, p.  231. 


\24    ABDOMINAL   WALL.  STOMACH,  AND  INTESTINES. 

larged  until  the  finger  can  be  introduced,  and  then  the  sac 
slit  up  on  it  as  a  guide.  If  the  omentum  is  then  found 
tilling  the  sac,  it  must  be  cautiously  unfolded  or  incised, 
for  it  is  probable,  especially  in  umbilical  hernia,  that  a 
strangulated  loop  of  intestine  will  be  found  in  its  center. 
( '.  I H visk  »N  op  THE  Stricture. — The  left  forefinger  is 
passed  up  into  the  neck  of  the  sac  by  which  the  stricture 
is  usually  constituted,  the  pulp  upward,  the  nail  pressing 
against  the  intestines  ;  if  the  stricture  lies  or  can  be  drawn 
outside  the  opening  in  the  abdominal  wall  through  which 
the  hernia  made  its  escape,  it  may  be  divided  freely  with- 
out risk,  but  if  it  lies  within  the  opening  the  division 
must  be  made  with  reference  to  the  anatomy  of  the  region. 
If  the  division  cannot  be  made  at  the  desired  point,  but 
only  at  some  other  where  an  incision  of  the  necessary  ex- 

Fig.  205. 


Hernia  knife. 


tent  would  be  dangerous,  the  stricture  must  be  slightly 
nicked  at  that  point,  and  advantage  then  taken  of  the  par- 
tial liberation  to  make  a  second  cut  in  the  proper  place. 
The  end  of  the  finger,  or  its  nail,  is  gently  engaged  in 
the  stricture,  its  pulp  against  the  selected  point  of  divi- 
sion, and  the  knife,  a  probe-pointed,  slightly  curved  bis- 
toury,  passed  on  the  Hat  along  its  palmar  surface  until  the 
point  has  passed  through  the  stricture.  The  surgeon  then 
turns  its  edge  upward  and  presses  it  against  the  stricture 
with  the  end  of  the  finger  on  which  it  rests.  A  slight 
crackling  announces  the  division,  which  must  be  extended 

or    repeated   at    different    points    until    the    linger    can    be 

passed  freely  through  into  the  abdomen. 

Instead  of  an  ordinary  probe-pointed  bistoury,  a  spe- 
cially constructed  hernia  knife  (Fig.  205)  is  often  used. 
It  i-  probe-pointed  and  its  cutting  c<\^c  not  more  than  an 


// E&NIO TOM F,  KEL 0 TOM  Y.  425 

inch  long.  The  knife  may  also  be  guided  upon  a  director 
instead  of  the  finger.  The  "  hernia  director"  is  broader 
than  the  ordinary  one,  and  sometimes  has  a  broad  flange 
on  each  side  to  keep  the  bowel  from  rolling  over  against 
the  edge  of  the  knife.  It  is,  however,  more  surgical  to 
cut  down  upon  the  constriction  layer  by  layer  and  then 
divide  it  from  without,  the  gut  being  protected  by  the 
ringer  or  a  director. 

J).  Examination  and  Return  of  the  Bowel. — 
The  bowel  should  be  gently  drawn  out  about  an  inch  in 
order  that  the  constricted  part  itself  may  be  examined, 
for  it  is  very  likely  to  be  badly  damaged.  If  the  entire 
loop  is  in  suitable  condition  it  must  be  carefully  cleaned 
of  all  blood  and  gradually  returned  into  the  cavity  of  the 
abdomen.  It  is  not  always  easy  to  decide,  however, 
whether  or  not  its  condition  is  suitable  for  return,  and 
some  surgeons  have  recommended  that  in  eases  of  doubt 
it  should  be  covered  with  warm,  wet  cloths  and  kept  under 
observation  for  some  time,  the  stricture,  of  course,  having 
been   previously  divided. 

A  very  great  change  in  the  color  of  the  loop  is  far 
from  proving  the  existence  of  gangrene.  A  deep  red 
vinous  color  does  not  preclude  recovery,  especially  if  the 
surface  has  not  lost  its  lustre  ;  but  if  it  is  black,  or  deep 
brown,  or  grayish-yellow,  or  if  it  is  dull,  flaccid,  or 
wrinkled,  it  is  certainly  gangrenous.  Of  course,  when 
the  characteristic  gangrenous  odor,  or  the  fecal  odor  con- 
sequent on  perforation,  exists,  there  can  be  no  doubt. 

Occasionally,  when  in  doubt  as  to  the  vitality  of  a  small 
part  of  the  intestine,  I  have  covered  it  in  by  a  few  Lem- 
bert  sutures  as  if  it  were  a  cut  in  the  wall. 

It  is  not  always  easy  to  return  the  intestines  even  after 
the  stricture  has  been  divided.  The  surgeon  should  try 
to  reduce  one  end  at  a  time,  by  squeezing  its  contents 
back  into  the  abdomen  and  pushing  the  gut  in  afterward. 
If  rupture  occurs,  and  the  bowel  is  otherwise  in  good 
condition,  it  must  be  closed  with  Lembert  sutures  and 
returned  into  the  abdomen. 

If  the  intestine  is  gangrenous,  an  artificial  anus   must 


426   ABDOMINAL   WALL,  STOMACH,  AND  TNTEST1NES. 

be    formed    or    the    damaged    portion    excised    and    the 
divided  ends  united  to  each  other  (enterorrhaphy). 

E.  Treatment  of  the  Omentum. — If  only  a  small 
amount  of  omentum  is  found  in  the  sac,  and  if  it  is  in 
good  condition,  it  may  be  returned  ;  but  if  there  is  much 
of  it,  or  if  it  is  inflamed,  or  gangrenous,  it  must  be  drawn 
further  out  and  resected  through  normal  parts  after  care- 
ful ligation  in  small  bundles  of  the  entire  breadth. 

Fig.  206. 


Bernia.    The  relations  of  the  femoral  and  interna]  abdominal  rings,  seen  from 
rithin  tin-  abdomen.     Right  side. 


Strangulated  Inguinal  Hernia. —  Iuguiual  hernia  may  be 
oblique  or  direct,  The  former  Leaves  the  abdomen  at  the 
interna]  (deep)  abdominal  ring,  having  the  deep  epigastric 
artery  on  the  inner  side  (Fig.  206),  passes  down  the  ingui- 
nal canal,  and  emerges  at  (lie  external   abdominal  ring 

I  Fig,   207);    the  latter  makes  its  way  through  I  lesselbaeh's 

triangle,  a  space  bounded  by  the  epigastric  artery,   Pou- 
part'fl  ligament,  and  the  rectus  abdominis  muscle  (Fig. 


HERNIOTOMY,  KELOTOMY 


427 


206),  and  also  emerges  at  the  external  abdominal  ring. 

The  former  is  by  far  the  more  common  variety. 

Operation. — The  parts  having  been  well  shaved  and  dis- 
infected, the  patient  is  anaesthetized  and  placed  upon  his 
back,  with  his  shoulders  slightly  raised.      An   incision  is 


Flo.  '2117. 


Internal   . 
abdominal  riin 

Epiy  utric  ar'sry 


Inguinal  hernia,  showing  the  transversalis  nm 
the  internal  abdominal  ring. 


tlie  transversalis  fascia,  and 


then  made  from  a  point  a  little  above  and  external  to  the 
external  ring  along  the  summit  of  the  swelling  to  its  lower 
end,  and  carefully  deepened  until  the  sac  is  reached.  This 
is  then  opened  by  pinching  it  up  and  incising  as  above 
described.  The  best  point  for  opening  it  is  at  its  extreme 
lower  end,  because  a  little  serum  is  usually  collected  there, 


428   ABDOMINAL  WALL.  STOMACH,  AND  INTESTINES. 

separating  it  from  the  bowel,  but  if  no  such  point  is  found 
the  neighborhood  of  the  neck  should  be  tried,  because  that 
part  is  usually  free  from  adhesions.  The  constriction, 
which  is  usually  in  the  neck  of  the  sac  if  the  hernia  is  old, 
is  then  sought  for,  and,  if  found  above  the  external  ring-, 
must  be  nicked  or  divided  directly  upward,  or  cut  down 
upon  from  without. 

If  it  can  be  positively  made  out  that  the  hernia  is  of 
the  oblique  variety,  the  cutting  should  be  done  on  the  outer 
side,  for  the  epigastric  artery  lies  close  to  the  inner  side  of 
the  internal  ring,  through  which  this  variety  passes ;  and 
if  it  is  known  to  be  of  the  direct  variety,  the  cutting  must 
be  done  upon  the  inner  side.  But,  unfortunately,  in  most 
cases  the  dragging  of  the  hernia  brings  the  two  rings  im- 
mediately opposite  each  other,  so  that  the  inguinal  canal 
can  no  longer  be  said  to  exist,  and  the  diagnosis  cannot  be 
made  with  certainty.  The  incision  must  then  be  made 
upward,  parallel  to  the  course  of  the  epigastric  artery. 

The  intestine  must  next  be  examined  to  ascertain  if  it 
is  in  a  fit  condition  to  be  returned ;  and  here  it  must  not 
be  forgotten  to  draw  down  an  inch  or  more  of  each  end  so 
that  the  part  which  has  undergone  constriction  may  also 
be  examined.  If  the  condition  is  satisfactory,  the  bowel 
is  returned  gradually,  not  en  nntssc}  and  the  wound  closed 
by  one  of  the  methods  about  to  be  described  for  radical 
cure,  preferably  Bassini's.  If  it  cannot  be  safely  returned, 
it  is  resected  or  fastened  in  the  wound,  as  in  enterostomy. 

Strangulated  Femoral  Hernia. — The  intestine  in  its 
descent  occupies  a  canal  which  begins  at  the  femoral  ring 
under  Poupart's  ligament,  between  the  free  arched  border 
of  Gimbernat's  ligament  and  the  femoral  vessels  (Fig. 
206),  and  ends  at  the  saphenous  opening  in  the  fascia  lata 
of  the  thigh.  After  passing  through  the  opening  it  turns 
upward  over  the  groin.  The  normal  length  of  the  canal 
i-  about  an  inch,  but  in  hernia-  of  long  standing  it  is 
much  shortened  by  the  approximation  of  its  two  end-. 

Tin-  seal  of  Stricture  is  now  thought  to  lie  in  most  cases  at 
the  saphenous  opening,  or  just    above  it,  and   not   at  the 


HEBNIOTOM  Y,  KELOTOM 1 ".  429 

base  of  Gimbernat's  ligament,  as  was  formerly  supposed; 
free  division  is  possible  at  the  former  point  on  the  upper 
and  inner  side  without  the  risk  of  injury  to  any  organ, 
except  possibly  the  spermatic  cord,  and  that  is  at  such  a 
distance  as  to  be  practically  out  of  harm's  way.  Under 
ordinary  circumstances,  Gimbernat's  ligament  can  also  be 
safely  divided  on  the  inner  side,  but  in  about  one  and  one- 
half  per  cent,  of  cases  the  obturator  artery  pursues  the 
anomalous  course  shown  in  Fig.  208,  and  then  lies  directly 
in  the  way  of  the  knife.  The  neck  of  the  sac  under  such 
circumstances  is  entirely  surrounded  ;  on  its  outer  side  are 
femoral  vessels,  above  is  the  common  trunk  of  the  epigas- 
tric and  obturator  arteries,  on  its  inner  side  the  obturator 


Variations  in  origin  and  course  Of  obturator  artery. 

artery,  below  it  the  bone.  The  only  safe  plan  of  relieving 
the  stricture,  therefore,  is  to  nick  it  slightly,  to  the  depth 
of  one  *>r  two  millimeters,  at  several  points  on  its  upper 
and  inner  borders,  or  fully  to  expose  the  ring  and  divide 
its  upper  inner  part  layer  by  layer  from  without  inward. 
The  coverings  of  the  hernia  are  thin  and  composed  of  the 
skin,  subcutaneous  tissue,  cribriform  fascia  sometimes, 
septum  crurale,  and  peritoneum. 

The  incision  may  be  straight  or  curved,  the  convexity 
directed  downward  and  outward,  or  T-^hapcd,  the  hori- 
zontal branch  being  made  along  Poupart's  ligament,  the 
other  passing  directly  downward  over  the  saphenous  open- 
ing, and  should  be  made  from  without  inward.  The 
-ingle    straight    incision   just    to    the    inner    side   of   the 


430  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

femoral  vessels  is  the  one  usually  employed.  The  under- 
lying tissues  must  be  divided,  and  the  sac  exposed  or 
opened  in  the  manner  described  under  General  Directions, 
and  the  seat  of  stricture  sought  for  and  divided  accord- 
ing to  the  rules  above  laid  down. 

The  gut  is  then  pulled  down  and  examined,  and  if  its 
condition  is  satisfactory  it  is  returned  and  a  radical  cure 
performed.     W  not,  it  is  resected  or  fastened  in  the  wound. 

Strangulated  Umbilical  Hernia. — Tt  is  generally  claimed 
that  true  umbilical  hernia,  that  is,  hernia  through  the  um- 
bilical ring,  is  almost  always  congenital,  and  that  the 
hernias  which  occur  during  adult  life  emerge,  not  through 
the  ring,  but  through  an  accidental  opening  in  the  linea 
alba  near  it,  and  therefore  deserve  the  name  of  peri-um- 
bilical  given  them  by  Gosselin.  While  this  condition, 
that  is,  of  escape  through  a  chance  opening  in  the  linea 
alba,  may  exist  in  some  cases,  Richet1  has  sought  to 
prove  by  anatomical  considerations  and  by  the  results  of 
the  examination  of  three  cases  of  hernia,  that  true  um- 
bilical hernia,  on  the  contrary,  is  the  rule,  and  the  other 
is  the  exception.  He  shows  that  the  weak  point  of  the 
ring  is  its  upper  portion,  and  (hat  when  the  cicatrix  is 
pressed  downward  and  given  a  semicircular  form  by  the 
hernia,  a  complete  ring,  which  seems  to  be  situated  above 
that  corresponding  to  the  vein  and  arteries,  is  constituted 
by  the  cicatrix  below  and  the  upper  part  of  the  opening 
above,  and  exactly  resembles  a  distended  accidental  per- 
foration. 

The  coverings  of  the  hernia  are  the  skin,  cellular  tis- 
3Ue,  and  peritoneum  ;  its  contents  are  the  small  intestine, 
sometimes  the  transverse  colon,  and  in  the  adult  the 
omentum. 

On  account  of  the  pathological  changes  which  take 
place  in  the  sic  and  its  contents,  it  is  best  to  undertake  a 
formal  laparotomy  if  the  hernia  is  strangulated  or  irre- 
ducible. An  incision  i-  made  gently  curving  outward 
around  one  side  of  the  base  of  the  hernial  tumor,  and  pro- 
longed a  couple  of  inches  above  and  below  it  in  the  me 
1  Anatomie  Mddico-C'hirurgicale,  Pari  II..  p.  378 


HERNIOTOMY,  KELOTOMY.  431 

dian  line.  The  incision  is  deepened  layer  by  layer  and 
the  peritoneum  opened  in  the  median  line  above  and  be- 
low the  neck  of  the  hernial  sac,  and  in  the  intermediate 
space  divided  on  the  finger  as  a  guide,  in  the  line  of  the 
cutaneous  incision  close  outside  the  neck  of  the  sac,  spar- 
ing the  margin  of  the  rectus  muscle  as  much  as  possible. 
A  sponge  protective  packing  is  placed  on  the  surrounding 
viscera,  and  an  incision  is  made  through  the  neck  and 
body  of  the  sac,  including  the  overlying  skin,  at  right 
angles  to  the  center  of  the  curved  incision  around  the 
base  of  the  hernial  tumor,  exposing  the  hernial  contents 
without  damaging  them. 

The  constriction  is  thus  relieved,  and  the  dissection  is 
continued  till  the  hernial  contents  are  freed  from  ad- 
hesions to  each  other  and  the  sac.  If  they  consist  of 
omentum  alone,  the  excess  is  excised  on  the  proximal 
side  of  the  strangulation  and  the  abdominal  wound 
treated  as  described  below.  If  of  intestine,  the  gut  is 
surrounded  by  warm  cloths  or  placed  in  the  abdomen  on 
sponge  protectives.  Then  the  hernial  sac,  together  with 
the  overlying  skin  and  the  umbilicus,  is  excised  with  di- 
vision of  the  peritoneum  close  around  the  neck  of  the  sac. 

The  intestine  is  next  inspected,  and  if  gangrene  is  pres- 
ent the  gut  is  resected  or  left  outside  the  partially  closed 
abdominal  wound  for  the  slough  to  separate.  A  couple 
of  Lembert  sutures,  or  a  stout  silk  loop  through  the  mes- 
entery, serve  to  retain  the  healthy  part  above  and  below 
the  damaged  area  in  the  margins  of  the  wound. 

If  the  gut  is  healthy,  after  excision  of  the  excess  of 
omentum  and  of  the  sac  with  its  overlying  skin  and  um- 
bilicus, the  sponge  protective  packing  is  removed,  the 
edges  of  the  sheaths  of  the  recti  muscles  are  freshened, 
and  the  abdominal  wound  closed  in  the  usual  way  with 
close  approximation  of  the  recti.  The  wound  is  then 
dressed  in  the  ordinary  manner. 

If  the  hernia  is  very  large  it  is  better  that  the  first  in- 
cision  should  be  made  in  the  median  line  and  prolonged 
upward  an  inch  or  two  above  the  hernial  orifice.  The  sac 
should   be  freely  but    very  carefully  opened    in  the  line  of 


432   ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

the  incision,  for  extensive  adhesions  are  often  present ;  or 
the  abdominal  cavity  may  be  opened  just  above  the  hernial 
orifice,  and  the  wall  of  the  latter  divided  at  its  upper  part. 
After  reduction  of  the  hernia  the  entire  circuit  of  the  ori- 
fice is  excised,  and   the  wound  closed  as  after  laparotomy. 

Strangulated  Obturator  Hernia. — A  long  incision  is  made 
parallel  to  the  femoral  vessels  and  about  an  inch  from 
them  on  the  inner  side.  The  pectineus  muscle  is  exposed 
and  divided,  as  are  also  any  fibers  of  the  obturator  externus 
whose  division  may  be  necessary  to  give  access  to  the  seat 
of  the  stricture.  The  relations  of  the  artery  and  nerve  to 
the  neck  of  the  sac  must  be  determined,  and  the  division 
made  in  such  a  direction  that  they  will  not  be  injured. 

If  the  gut  can  be  returned  into  the  abdomen  a  radical 
cure  can  then  be  attempted.  This  consists  simply  in  iso- 
lation of  the  sac,  its  ligation  as  high  as  possible  after  re- 
duction of  the  hernia,  excision  of  the  distal  portion,  closure 
of  the  orifice  with  silkworm-gut,  and  suture  of  the  wound 
in  the  overlying  soft  parts. 

The  same  may  be  said  of  hernia  occurring  in  such  un- 
usual localities  as  Petit's  triangle,  the  great  sacrosciatic 
foramen,  etc 

If  the  gut  is  gangrenous  it  must  be  fastened  in  the 
wound  as  in  enterostomy,  or  resected  if  the  condition  of 
the  patient   permits. 

RADICAL  CURE  OF  INGUINAL  HERNIA. 

Czerny's  Operation.' — An  incision  is  made  three  or  four 
inches  long  over  the  inguinal  canal  and  upper  end  of  the 
hernial  sac,  with  its  center  opposite  the  external  abdominal 
ring.  The  aponeurosis  of  the  external  oblique  muscle  and 
(lie  sac  arc  exposed,  and  the  neck  of  the  latter  dissected 
free  from  the  surrounding  parts.  This  is  most  easily  done 
after  the  body  of  the  sac  has  been  opened  and  tin;  hernial 

< tents  freed  from  adhesions  and  reduced,  and  one  finger 

passed  through  the  interior  of  the  neck  of  the  sac  to  make 
it  tense  and  serve  as  a  guide  in  the  dissection. 

The  neck  of  the  sack  is  drawn  down  ami  tied  off  as 
i  W'i.n.  med.  W'nrli..  1S77,  N,,.  21. 


RADICAL  CUBE  OF  INGUINAL  HERNIA.  133 

high  up  as  possible  or  at  the  internal  abdominal  ring, 
with  a  stout  catgut  ligature,  which  is  drawn  tight  over 
the  tip  of  the  finger  placed  inside  the  neck  to  prevent 
prolapse  of  the  hernia  and  its  inclusion  in  the  ligature. 
Czerny  drew  the  serous  surface  together  by  a  continuous 
(purse-string)  silk  suture  passed  from  the  inside.  The 
sac  distal  to  the  Ligature  is  excised,  though  any  part  or  the 
whole  of  it  can  be  left  undisturbed  if  it  seem  advisable. 

The  sides  of  the  opening  in  the  abdominal  wall  are 
drawn  together  with  catgut  or  silkworm-gut  sutures 
passed  through  all  the  layers  between  the  skin  and  peri- 
toneum, and  closed  over  the  cord,  which  is  left  to  emerge 
through  as  small  an  opening  as  possible  at  the  lower  angle 
of  the  suture  line.  The  skin  wound  is  closed  with  in- 
terrupted fine  silk  sutures,  and  if  it  seem  necessary  a 
strip  of  rubber  tissue  is  placed  in  the  lower  angle  of  the 
wound  for  drainage. 

Ball '  applied  torsion  to  the  sac  and  its  neck  before 
ligating  and  excising  the  distal  portion.  Barker  2  dissects 
out  and  divides  the  neck  of  the  sac,  transfixes  and  ties  it 
off  with  a  silk  ligature,  and  then  uses  the  long  ends  of 
the  latter  as  a  suture  to  close  the  internal  ring  and  over- 
lviuo-  wound.  He  does  not  remove  the  body  of  the  sac. 
The  rest  of  the  wound  is  closed  by  both  as  in  Czerny's 
operation.  Macewen  3  dissects  out  the  sac,  its  neck, 
and  the  immediately  adjoining  peritoneum.  He  then  in- 
verts and  reinverts  the  apex  of  the  sac  into  its  neck, 
transfixes  and  ties  together  with  a  firm  catgut  or  silk  liga- 
ture the  mass  thus  formed  and  fastens  it  on  the  inner  sur- 
face of  the  internal  abdominal  ring.  The  latter  is  closed 
by  suturing  the  conjoined  tendon  to  the  inner  surface  of 
Poupart's  ligament.  The  external  ring  is  narrowed  as 
much  as  possible  by  silkworm-gut  stitches  and  the  cuta- 
neous wound  united  over  it. 

The  main  feature  of  the  last  three  operations  is  the 
attempt,  to  obliterate  the  funnel-shaped  depression  leading 

'Brit.  Med.  Jour.,  1887,  II.,  p.  1272. 
« Ibid.,  p.  1203. 
"Ibid.,  i>.  L263, 
28 


I.;  I    ABDOMINAL   WALL,  stomach.  AND  INTESTINES. 

into  the  Deck  of  the  hernial  sac  and  to  substitute  at  this 

point  an  elevation. 

Kocher's  '  method  has  yielded  excellent  results,  and  is 
as  follows  :  An  incision  three  or  four  inches  long  is  made 
in  the  long  axis  of  the  hernial  tumor  ;  its  center  is  over 
the  external  ring  ;  only  the  skin  and  subcutaneous  tissue 
are  divided  ;  none  of  the  external  oblique  muscle  is  cut. 
After  dissecting  out  the  body  and  neck  of  the  sac  up  to 
the  internal  abdominal  ring  and  reducing  the  hernia,  a 
iino-er  i-  passed  up  the  inguinal  canal  and  on  its  tip  as  a 
director  an  artery  clamp  is  forced  through  the  external 
and  internal  oblique  and  transversal  is  muscles  at  a  point 
about  half  an  inch  to  the  outer  side  of  the  internal  ring. 
Without  removing  it  from  the  puncture  the  clamp  is 
passed  <>n  down  the  inguinal  canal  and  made  to  seize  the 
apex  of  the  sac,  which  is  then  drawn  up  and  pulled 
through  the  puncture  and  twisted  into  a  round  cord.  The 
latter  is  laid  upon  the  outer  surface  of  the  external  oblique 
and  lower  down  in  the  inguinal  canal  and  secured  there 
by  five  or  six  sutures  passed  through  all  the  structures 
(except  the  skin,  subcutaneous  tissue,  and  peritoneum)  on 
each  side  of  the  inguinal  canal.  The  last  one  or  two 
sutures  through  the  extremity  of  the  twisted  sac  and  the 
pillars  of  the  external  ring  draw  the  latter  together.  The 
cutaneous  wound  is  then  closed  and  dressed  antiseptically. 

Bassini's  Operation.- — An  incision  three  or  four  inches 
long  is  made  from  the  level  of  the  upper  part  of  the  in- 
ternal abdominal  ring  obliquely  downward  over  the  long 
axis  of  the  hernial  tumor.  The  aponeurosis  of  the  ex- 
ternal oblique  muscle  is  exposed  and  divided  from  the 
upper  border  of  the  internal  abdominal  ring  over  the 
whole  length  of  the  inguinal  canal,  and  the  neck  of  the 
hernial  sac  isolated  from  the  cord  and  surrounding  part-. 
(Fig.  _!<•'.•.)  The  body  of  the  sac  is  nicked  and  opened 
sufficiently  to  free  its  contents   from   possible  adhesions, 

and  to  permit    reduction  of  the  hernia    by  a  linger  passed 

through  the  interior  of  the  neck  of  the  sac  to  it-  abdominal 

1  Annals  Surg.,  1892,  Vol.  16,  p.  ■"»'»;,. 
tralb.  i.  '  air.,  1-'.'".  Vol.  I",  p.  129. 


RADICAL   CURE  OF  INGUINAL  HERNLA. 


4:;.-> 


orifice.  The  neck  is  then  drawn  down,  dissected  free,  and 
encircled  or  transfixed  as  high  nj)  as  possible  by  a  stout 
catgut  ligature,  which  is  drawn  tight  over  the  tip  of  the 
finger  still  kept  inside  the  neck  of  the  sac  to  prevent  the 
prolapse  of  any  visens  and   its   inclusion   in   the  ligature. 


Fig.  209. 


.1.  A,  A.  Subcutaneous  cellular  tissue.  E.  Spermatic  c»nl. r  /;,  <\  Aponeurosis 
of  external  oblique  divided  and  turned  back.  <•.  Epigastric  vessels.  /•'.  Internal 
oblique  and  transversalis  muscles  ami  vertical  fascia  of  Cooper. 


The   lower   portion  of  the  sac  is  then    dissected   out  and 
excised. 

The  margins  of  the  wound,  including  the  divided  apo- 
neurosisof  the  external  oblique  muscle,  are  well  retracted, 
and  on  the  outer  side  of  the  internal  abdominal  ring  and 
inguinal  canal,  the  upper  border  of  Poupart's  ligament  is 


136  ABDOMINAL   WALL,  stomach.  AND  INTESTINES. 

exposed;  and  on  the  inner  side  the  conjoined  edge  of  the 
internal  oblique  and  transversalis  muscles  and  the  trans- 
versalis  fascia.  After  raising  the  cord  these  structures  on 
the  inner  side  of  the  internal  abdominal  ring  and  inguinal 
canal  are  united  beneath  the  cord  to    Poupart's  ligament 


Fig.  210. 


Suture  of  the  conjoined  tendon  and  I  ransversalis  fascia  |  /•')  i"  the  posterior  bor- 
dei  of  Poupart's  ligament  (/>).  E.  The  cord.  B,  C.  Aponeurosis  of  the  external 
oblique, 

by  interrupted  silkworm-gul  <>r  catgut  sutures  extending 
upward  from  the  cresl  of  the  pubes  (ill  only  enough  space 
In  Hi,'  upper  and  outer  pari  (if  tin-  internal  abdominal 
ring  is  1 1  -  ft  for  the  cord  to  pass  without  undue  compres- 
sion. The  lower  two  suture-  should  include  the  outer 
border  of  the  reel  us  muscle.     (  Fig.  210.) 


TtADICAL   CURE  OF  TNGUINAL   HERNIA. 


431 


The  cord  is  then  placed  on  this  new  posterior  wall  oi 
the  inguinal  canal  and  the  divided  aponeurosis  of  the 
external  oblique  muscle  united  over  it  by  catgut  sutures, 
1  wing  as  small  an  aperture  as  possible  at  the  lower  angle 
for  the  cord  to  emerge.  (Fig.  '2\  1.)  The  skin  wound  is 
sutured  with   interrupted  silk   and  dressed   antiseptically 


Fro.  211. 


Suture  of  the  divided  aponeurosis  of  the  external  oblique  i. />'.  C)  over  the  sper- 
matic cord  (/■:). 

without   drainage,    and   in   children    it   is   wise   to  add  a 
plaster-of-Paris  spica. 

Bassini  uses  silk  for  the  buried  sutures  and  forms  the 
new  internal  abdominal  ring  about  half  an  inch  to  the 
inner  side  of  the  anterior  superior  spine  of  the  ilium;  that 
is,    he    divides    the    internal    oblique    and     transversalis 


t38    {BDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 

muscles  above  and  to  the  outer  side  of  the  internal 
abdominal  ring,  transplants  the  cord  to  the  outer  extrem- 
ity of  this  incision,  fastens  the  internal  oblique  and  trans- 
versalis  under  it  and  the  external  oblique  over  it.  If  the 
hernia  is  complicated  by  undescended  testicle  Bassini  un- 
folds the  vas  deferens  by  a  careful  dissection  and  brings 
the  testicle  down  from  the  inguinal  canal  and  sutures  it 
to  the  bottom  of  the  scrotum.  If  this  is  impossible  castra- 
tion is  performed. 

Lauenstein  places  the  testicle  in  the  abdomen  along  with 


Fig.  212. 


Fig.  213. 


Fig.  214. 


Method  "l'  tying  off  omentum  in  sections. 


the  stump  of  the  sac.  In  congenital  hernia  enough  of  the 
fundus  of  the  sac  should  be  left  to  form  a  tunica  vaginalis. 
In  direct  inguinal  hernia  the  orifice  of  the  hernia  is 
formed  by  the  external  abdominal  ring,  the  neck  of  the 
sac  i-  shorl  and  passes  over  the  cord  and  lies  to  the  inner 
side  of  the  deep  epigastric  artery.     Alter  tying  off  the 

neck  of  the  sae  of  a  direct    inguinal    hernia,  the  parts  on 

the  inner  aide  of  the  abdominal  orifice,  between  the  peri- 
toneum ami  external  oblique  tendon,  are  sutured,  as  in 
ili«'  indirect  variety,  to  I 'uu | tart'.-  ligament. 


RADICAL   CURE  OF  INGUINAL   HERNIA.         439 

If  the  hernia  is  an  epiplocele  the  excess  of  omentum  is 
tied  off  with  stout  catgut  close  to  the  neck  of  the  sac 
and  excised.  If  it  is  very  large,  the  pedicle  should  be 
spread  out  and  tied  in  sections,  as  illustrated  in  Figs.  212, 
213,  '214. 

ffalsted's  operation  '  is  as  follows  :  The  aponeurosis 
of  the  external  oblique  and  the  external  abdominal  ring- 
are  exposed  by  an  incision  starting  some  5  centimeters 
above  and  external  to  the  internal  ring  and  extending  to 
the  spine  of  the  pubes.  In  this  line  the  aponeurosis  of 
the  external  oblique  and  the  fibers  of  the  internal  oblique 
and  transversalis  muscles  and  the  transversalis  fascia  are 
cut  from  the  external  ring  to  a  point  about  2  centimeters 
above  and  external  to  the  internal  ring.  The  peritoneum 
and  neck  of  sac  are  thus  exposed,  the  latter  opened,  the 
hernia  reduced,  and  the  neck  of  the  sac  ligated  or  sutured 
and  the  distal  portion  excised.  The  cord  is  then  isolated, 
and,  after  removing  all  but  one  or  two  of  its  veins,  it  is 
transplanted  to  the  outer  angle  of  the  incision.  Beneath 
it  mattress  sutures  are  passed  :  on  the  inner  side  through 
the  aponeurosis  of  the  external  oblique,  the  internal 
oblique  and  transversalis  muscles,  and  transversalis 
fascia  ;  on  the  outer  side  through  the  aponeurosis  of  the 
external  oblique,  Poupart's  ligament,  and  the  transversalis 
fascia.  This  obliterates  the  canal  and  places  the  cord  on 
the  outer  surface  of  the  external  oblique  aponeurosis, 
where  it  is  covered  by  skin  and  subcutaneous  tissue  only. 
The  cutaneous  wound  is  then  closed  by  superficial  sutures 
and  dressed  antiseptically  without  drainage. 

M'Burney's  Operation.- — The  incision,  division  of  the 
aponeurosis  of  the  external  oblique  muscle,  and  the  treat- 
ment of  the  sac  are  the  same  as  in  Bassini's  operation. 

Sutures  are  then  passed  through  the  skin,  the  aponeu- 
rosis of  the  external  oblique  (including  the  inner  pillar 
of  the  external  ring),  and  the  conjoined  tendon  firmly 
binding  these  structures  together  with  deep  inversion  of 
the  skin  and  usually  covering  in  the  cord.      On  the  oppo- 

1  Annals  of  Surgery,  1893,  Vol.  17,  p.  542. 

2  N\-\\  York  Medical  Record.  1889,  Vol.  35,  p.  312. 


I  Mi    ABDOMINAL    WALL.  STOMACH,  AND  INTESTINES. 

site  side  of  the  wound  the  skin  is  inverted  and  sutured  to 
Poupart's  ligament,  including  at  the  lower  part  the  outer 
pillar  of  the  external  ring  ;  the  lower  angle  of  the  wound 
is  sutured  with  silk  and  drawn  together  above  with  two 
or  more  tension  sutures  passed  through  the  skin  and 
superficial  fascia  and  tied  over  pledgets  of  iodoform 
gauze.  The  space  of  about  one-fifth  of  an  inch  left  be- 
tween the  lips  of  the  wound  is  packed  snugly  with  iodo- 
form gauze  down  to  the  peritoneum  to  insure  healing  by 
granulation  and  the  obliteration  of  the  inguinal  canal  by 
dense  cicatricial  tissue.  This  operation  was  at  first  ex- 
tensively used,  but  of  late  has  largely  yielded  place  to 
Bassini's  ;  it  is,  however,  a  safer  and  surer  operation  for 
the  less  experienced,  and  for  strangulated  and  infected 
eases  in  which  the  wound  cannot  safely  be  closed.  It  is 
also  worthy  of  remembrance  in  the  history  of  the  evolu- 
tion of  radical  cure  that  this  was  the  first  method  in  which 
the  aponeurosis  of  the  external  oblique  was  divided  and 
the  internal  ring  freely  exposed  in  the  effort  to  ensure 
complete  removal  of  the  sac. 

Eadical  Cure  of  Umbilical  Hernia. — If  the  hernia  is  irre- 
ducible, the  treatment  is  the  same  as  that  described  for 
strangulated  umbilical  hernia. 

If  reducible,  an  incision  is  made  which  encircles  the 
base  of  the  hernial  tumor,  extending  an  inch  or  two  above 
and  below  it  in  the  median  line,  and  deepened  layer  by 
layer  till  the  abdominal  cavity  is  opened  at  one  extremity 
ni'  the  incision.  A  Hat  sponge  is  inserted,  and  on  the 
linger  as  a  guide  the  peritoneum  is  divided  in  the  line  of 
the  cutaneous  incision  around  the  neck  of  the  sac,  and  the 
latter  excised  together  with  the  body  of  the  sac,  the  over- 
lying  skin,  and  the  umbilicus.  The  peritoneum  is  then 
sutured  with  catgut,  the  edges  of  the  sheaths  of  the  sepa- 
rated recti  muscles  are  freshened  throughout  the  whole 
length  of  the  wound,  and  the  recti  closely  approximated 
with  interrupted  catgut  or  silkworm-gul  sutures.  <  >ver 
thifi  the  superficial  fascia  and  skin  are  united  with  silk 
iil'tcr  excision  of  any  redundant  portions. 

Radical  Cure  of  Femoral  Hernia. — Starting   from    Pou- 


UECTUM.  -1-11 

part's  ligament  a  vertical  incision  some  three  or  four  inches 
long  is  made  jusl  to  the  inner  side  of  the  femoral  vessels. 
It   musl   be  deepened  carefully,  as  the  coverings  of  the 

hernia  in  iv  be  very  thin  and  consist  only  of  skin  and 
superficial  fascia  if  the  hernia  has  passed  through  the  cribri- 
form fascia.  After  exposing  and  opening  the  sac  and  re- 
turning the  bowel  or  possibly  excising  the  omentum,  the 

neck  of  the  sac  is  isolated  and  tied  off  high  up  with  silk 
or  stout  catgut. 

Various  procedures  have  been  adopted  for  the  succeed- 
ing steps  in  the  operation.  Billroth  removed  the  portion 
of  the  sac  distal  to  the  ligature  and  sutured  the  middle 
third  of  Poupart's  ligament  to  the  fascia  covering  the 
abductor  muscles,  or  to  that  on  the  inner  aspect  of  the 
femoral  vessels.  Berger  united  Poupart's  ligament  to 
the  pubic  portion  of  the  fascia  lata  covering  the  pecti- 
nens  muscle.  A  flap  cut  from  the  latter  muscle  has  been 
turned  up  and  fastened  in  the  femoral  ring-. 

Macewen  employs  the  same  principle  as  for  the  cure  of 
inguinal  hernia  (7.  v.);  i.  e.,  the  sac  is  folded  into  a  pad 
and  secured  on  the  inner  surface  of  the  femoral  ring, 
which  is  then  drawn  together  with  silk  or  silkworm-gut 
passed  through  the  available  soft  parts  adjoining  its  boun- 
daries. Koeher  exposes  the  sac  and  saphenous  opening 
by  a  vertical  incision,  but  does  not  divide  the  fascia  lata 
overlying  the  canal  ;  the  sac  is  then  drawn  through  a 
puncture  in  Poupart's  ligament  just  over  the  canal  and 
twisted,  and  its  extremity  is  brought  down  over  the  liga- 
ment into  the  canal  again,  and  secured  there  by  two  or 
three  silk  sutures  passed  through  it  and  Poupart's  liga- 
ment and  the  pectineal  fascia. 

After  obliterating  the  track  of  the  hernia  by  whatever 
method  is  adopted,  the  external  wound  is  closed. 

RECTUM. 

Anatomy. — The  rectum  is  from  six  to  eight  inches 
long,  and  for  about  its  first  three  inches  is  supplied  with 
a  mesorectum.  In  front  the  peritoneum  descends  to 
within  about  three  inches,  and  behind  about  five  inches 


442   ABDOMINAL   WALL.  STOMACH,  AND  INTESTINES. 

from  the  anus.  The  second  portion  of  the  rectum  is  in 
relation  in  front,  in  the  male,  with  the  trigonum  of  the 

1  (ladder,  the  vcsicula?  seminales,  and  the  vasa  deferentia 
and  the  prostate,  the  posterior  margin  <>f  which  can 
normally  he  reached  by  the  finger.  In  the  female  this 
portion  of  the  rectum  is  attached  to  the  posterior  vag- 
inal wall. 

Below  the  prostate  the  levatores  ani  join  the  rectum 
from  one  and  a-half  to  two  inches  from  the  anus,  at  a 
point  just  above  the  internal  sphincter.  The  superior 
hemorrhoidal  artery  lies  on  the  outer  surface  of  the  rectum 
behind,  a  little  to  the  left  of  the  middle  line,  till  within 
about  four  inches  of  the  anus.  It  then  divides  into  its 
terminal  branches,  which  have  a  longitudinal  distribution 
between  the  mucous  and  muscular  coats  and  communicate 
freely  about  the  anus. 

The  veins  have  a  similar  distribution,  and  communicate 
through  the  superior  hemorrhoidal  with  the  portal  system, 
and  through  the  middle  and  inferior  hemorrhoidal  with 
the  internal  iliac  veins.  The  sphincter  is  supplied  by  the 
fourth  sacral  nerve. 

IMPERFORATE  ANUS  OR  RECTUM. 
In  order  to  understand  their  different  congenital  deform- 
ities, ii  i-  essential  to  bear  in  mind  the  manner  in  which 
ill-'  rectum  and  anus  are  developed.  The  rectum,  like 
the  rest  of  the  intestine,  is  formed  by  the  third  blastodermic 
layer  of  the  ovule,  mid  originally  communicates  with  the 
pedicle  «>f  the  allantoid  vesicle,  that  which  afterward 
becomes  the  bladder  and  the  posterior  portion  of  the 
urethra.  The  anus,  mi  the  other  hand,  is  formed  by  a 
dimple  in  the  outer  blastodermic  layer,  the  one  which 
form-  the  epidermis.  In  the  ordinary  course  of  evente 
the  communication  between  the  rectum  and  the  bladder 
or  urethra  closes,  and  another  forms  between  the  rectum 
and  anus  by  absorption  of  the  layer  of  tissue  between 
them.  The  malformations  are  the  result  of  arrest  of  de- 
velopment of  the  colon,  rectum,  or  anus,  or  of  the  persist- 
ence of  the  septum,  and  present  several  varieties. 


IMPERFORATE  ANUS  OR  RECTUM.  443 

The  first,  and  slightest,  is  not  a  true  aires!  of  develop- 
ment, but  a  simple  closure  of  the  orifice  of  the  anus  by  a 
tegumentary  layer  or  by  adhesion  of  its  sides,  the  deep 
oommunicatioD  between  it  and  the  rectum  being  complete 
This  requires  only  separation  of  the  adherent  edges  with  a 
director,  or  division  of  the  layer  with  a  knife. 

2.  The  rectum  and  anus  may  be  fully  developed,  but 
the  thin  membranous  diaphragm  between  them  may  per- 
-i~t.  like  the  hymen  in  the  vagina.  The  treatment  of  this 
also  is  simple  :  crucial  incision  or  large  puncture  of  the 
membrane. 

'■'>.  The  anus  may  be  entirely  absent,  while  the  rectum 
is  normally  developed  ;  the  distance  between  the  lower 
end  of  the  latter  and  the  surface  being  from  half  an  inch 
to  an  inch. 

4.  The  anal  cul-de-sac  being  properly  developed,  the 
rectum  or  colon  may  terminate  at  any  distance  above  it, 
or  may  even  not  exist  at  all,  being  represented  by  a 
fibrous  cord  extendino-  from  the  ileo-ca?cal  valve  to  the 
anus. 

5.  The  arrest  of  development  may  involve  both  the 
anus  and  the  rectum. 

(J.  The  rectum  may  open  into  the  bladder,  urethra,  or 
vagina. 

It  is  often  exceedingly  difficult  to  determine  the  char- 
acter of  the  malformation  during  life,  and  yet  it  is  very 
important  that  this  should  be  done,  for  if  the  impervious- 
ness  begins  at  a  point  too  high  up  to  be  reached  through 
the  perineum,  the  only  possibility  of  relief  is  in  the  estab- 
lishment of  an  artificial  anus  in  the  lumbar  or  inguinal 
region.  Depaul '  says  that  when  the  obstruction  begins 
at  the  ileo-ca?cal  valve  the  transverse  distention  of  the  ab- 
domen is  much  less  than  in  rectal  obstruction. 

I?  the  surgeon  decides  to  go  in  search  of  the  blind  end 
of  the  rectum  and  create  an  anus  in  the  perineum,  he 
must  make  an  incision  in  the  median  line  from  the  scro- 
tum to  the  tip  of  the  coccyx,  after  having  previously  intro- 
duced a  sound  into  the  bladder  if  the  patient  is  a  boy,  or 
'Bull.  <le  la  Soeit'U'  de  Chirurgie,  1S77,  p.  •">.">•'>. 


444   ABDOMINAL   WALL.  STOMACH,  AND  INTESTINES. 

into  the  vagina  if  a  girl.  He  then  divides  the  tissues 
layer  by  layer  in  the  line  of  the  incision,  feeling-  ;it  each 

step  for  the  distended  rectum,  which  can  sometimes  be 
seen  and  felt  to  bulge  downward  when  the  child  strains  or 
cries.  Or  an  exploratory  puncture  may  he  made,  and 
the  needle  or  trocar  used  as  a  guide  if  the  bowel  is 
reached  by  it. 

The  search  for  the  bowel  should  be  made  in  the  direc- 
tion of  the  axis  of  the  anal  cul-de-sac,  if  the  latter  is  suffi- 
ciently developed,  and  advantage  taken  of  the  fact  pointed 
out  by  M.  Forget,  '  that  a  fibrous  cord,  representing  a  ru- 
dimentary portion  of  the  rectum,  occupies  more  or  less  of 
the  distance  separating  the  two.  If,  on  the  contrary,  the 
anus  is  lacking,  the  search  must  be  made  toward  the  con- 
cavity of  the  sacrum.  Yerneuil  proposed  to  excise  the 
coccyx,  so  as  to  diminish  the  danger  incurred  during  the 
search,  but  as  this  may  be  followed  by  prolapse  of  the 
rectum  it  should  be  practised  only  when  a  simple  incision 
has  proved  insufficient. 

When  the  end  of  the  bowel  is  reached  it  must  be  seized 
with  pronged  forceps,  or  two  stout  ligatures  must  be  passed 
through  it,  and  it  must  be  partly  separated  from  the  ad- 
joining tissues,  drawn  down,  opened,  and  made  fast  to  the 
integument  or  the  margin  of  the  anus.  The  anterior  and 
posterior  portions  of  the  cutaneous  incision  must  finally  be 
closed  by  sutures.  It  would  be  perfectly  proper  when  in 
doubt  as  to  the  presence  or  position  of  the  rectum  to  open 
the  abdomen  in  the  median  line, and  then,  after  ascertain- 
ing the  conditions,  if  necessary  perform  a  colostomy. 

When  the  rectum  opens  into  the  vagina  it  may  be 
reached  through  a  median  or  crucial  incision  in  the 
perineum,  separated  from  the  vaginal  wall  with  a  knife  or 
curved    scissors,  and    drawn  down   and  fastened  as    before. 

The  former  opening  will  then  close  spontaneously. 

PROLAPSE   OF   THE   RECTUM. 

'flic    muCOUS    membrane   of  the    rectum    is   very  loosely 
attached    to    the  muscular  coat,  and  when    the  sphincter  is 
1  Hull,  de  la  SocteU  de  (  hirurgie.  1863  and  1S77. 


PROLAPSE  OF  THE  RECTUM.  445 

relaxed  or  disabled  prolapse  may  occur  to  a  degree  that 
requires  operative  interference.  This  interference  may  in- 
volve the  mucous  membrane  alone,  or  it  may  also  include 
the  anus  or  the  entire  rectum.  In  the  first  ease  the  indi- 
cation is  to  promote  adhesions  between  the  mucous  and 
muscular  coats,  or  to  remove  portions  that  may  be  in  ex- 
cess ;  in  the  second  to  narrow  the  anal  orifice,  or  fasten  the 
posterior  portion  of  the  bowel  to  the  firm  tissues  near  the 
sacrum  by  sutures.  The  former  is  accomplished  by  making 
deep  longitudinal  incisions  through  the  mucous  membrane, 
or  by  pinching  up  folds  at  three  or  four  different  points 
and  tying  a  strong  ligature  about  each.  The  incisions  are 
likely  to  give  rise  to  severe  hemorrhage,  and  consequently 
the  method  has  fallen  into  disuse ;  the  actual  cautery, 
however,  applied  at  points  or  in  lines,  has  been  used  as  a 
substitute  as  follows  : 

In  a  slight  or  partial  prolapse  the  bowels  are  emptied 
in  advance'  and  the  parts  reduced  and  put  ou  the  stretch 
with  the  bivalve  speculum.  The  point  of  a  Paquelin 
cautery  is  drawn  the  whole  length  of  the  prolapse  in  four 
longitudinal  lines  about  a  quarter  of  an  inch  wide  and 
equally  distant  from  each  other,  without  destroying  the 
entire  thickness  of  the  mucous  membrane.  To  avoid 
penetrating  too  deeply  Cripps  advises  that  the  cautery 
be  used  at  a  black  heat  only.  If  the  skin  about  the  anus 
is  not  touched  the  afterpain  is  slight.  A  tube  reaching 
above  the  sphincter  is  inserted  to  give  exit  to  flatus,  while 
the  bowels  are  kept  confined  for  several  days.  For  sev- 
eral weeks  thereafter  the  patient  must  defecate  in  the 
recumbent  position  and  avoid  straining  efforts,  while  the 
adhesions  caused  by  the  cauterization  become  firm  between 
the  mucous  and  muscular  coats. 

There  are  two  methods  of  narrowing  the  anal  orifice. 
Dupuytren  pinched  up  with  forceps  several  of  the  radiat- 
ing folds  of  integument  and  cut  them  off  with  curved 
scissors,  trusting  to  cicatricial  retraction  for  the  narrow- 
ing he  desired. 

Robert  made  two  incisions,  extending  from  the  extrem- 
ities of  the  transverse  diameter  of  the  anus  to  the  tip  of 


440   ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

the  coccyx,  removed  the  skin,  subcutaneous  tissue,  and 
portion  of  the  sphincter  contained  within  the  V  thus 
marked  out,  and  brought  the  sides  of  the  gap  together 
with  sutures. 

Rectopexy.— In  cases  of  extensive  prolapse  the  rectum 
has  been  secured  in  the  concavity  of  the  sacrum  behind  or 
to  the  abdominal  wall  in  front  or  in  the  left  inguinal  region. 

For  the  first  procedure  an  incision  is  made  in  the  me- 
dian line  from  just  behind  the  anus  to  the  tip  of  the 
coccyx,  and  deepened  backward  and  upward  till  the 
concavity  of  the  sacrum  is  reached.  A  catgut  suture  is 
then  passed  through  the  fibrous  tissue  in  front  of  this 
bone,  and  through  the  back  of  the  rectum  without  enter- 
ing its  lumen,  and  the  wound  either  closed  immediately 
or  after  two  or  three  days,  during  which  it  is  lightly 
packed. 

To  secure  the  rectum  to  the  anterior  abdominal  wall, 
the  peritoneal  cavity  is  opened  in  the  median  line  just 
above  the  pubes,  and  the  gut  secured  at  the  peritoneal 
edge  (if  the  wound,  as  in  hysteropexy,  by  a  silk  suture 
passed  through  the  whole  thickness  of  the  abdominal  wall, 
and  the  anterior  longitudinal  band  of  muscular  fibers  in 
the  rectum.  The  lumen  of  the  latter,  of  course,  must  not 
be  entered. 

In  the  left  inguinal  region  the  abdomen  is  opened  as 
for  colostomy,  and  the  upper  end  of  the  rectum  fastened  to 
the  wall  near  the  wound  in  a  similar  manner,  or  by 
a  suture  passed  through  the  whole  thickness  of  the  meso- 
reetum  and  parietal  peritoneum.1 

Ablation. —  For  pronounced  cases  with  gangrene  pres- 
ent or  threatening  Treves z  divides  the  rectum  circularly 
layer  by  layer  at  the  mueo-eutaneous  junction,  taking  care 
to  avoid  injury  to  any  small  intestine  which  may  have  be- 
come herniated  into  the  pouch  formed  by  the  prolapse. 

The  <-iit  ed^es  of  the  skin  and  intestinal  mucous  mem- 
brane arc  then  united  with  catgut.  If  the  peritoneum  is 
opened  the  wound   must   be  immediately  closed. 

'  Berg.  Annala  Surg.,  1893,  Vol.  XVII.,  p.  ■"-7:;. 
Lancet,  L890,  Vol.  I.,  ]>■  37G. 


FIST  I' LA.  447 

Torsion. — When  the  sphincter  has  been  destroyed  or 
removed  Gerster1  supplies  a  substitute  by  twisting  the 
rectum  on  its  long  axis  till  it:-  walls  form  a  rather  close 
spiral.  After  isolating  from  two  to  five  inches  of  its 
lower  end  the  gut  is  turned  through  half  a  circle  or  more, 
and  it-  free  extremity  sutured  t<»  the  margin  of  the  skin. 

Rectotomy. — There  is  occasionally  found,  especially  in 
women,  a  form  of  stricture  occupying  the  lumen  of  the 
rectum  like  a  thin  perforated  diaphragm,  which  is  prob- 
ably  the  result  of  a  partial  persistence  of  the  foetal  mem- 
brane between  the  anal  portion  which  is  developed  from 
below  upward  by  the  dimpling  of  the  -kin,  and  the  rectal 
portion  which  comes  down  from  above  to  meet  it.  For 
the  treatment  of  this,  after  emptying  the  bowels,  the 
sphincter  is  first  very  thoroughly  dilated  and  then  a 
blunt  director  is  forced  through  the  base  of  the  stric- 
ture in  the  posterior  median  line  and  brought  back 
into  the  rectum  in  the  same  line  above  it.  By  hook- 
ing the  finger  or  a  loop  of  stout  wire  over  the  point  of 
the  director  the  stricture  can  be  drawn  down  within  reach 
from  the  anus  ami  divided  layer  by  layer,  and  all  bleed- 
ing point-  secured  with  ligature-.  A  drainage  tube  and 
light  packing  are  passed  through  the  anus  to  the  point  of 
division. 

Stricture-  more  extensive  than  these,  yet  not  suitable 
for  excision,  arc  divided  with  the  knife  or  cautery  in  the 
median  line  posteriorly  carrying  the  division  through  the 
rectal  wall  below  the  stricture,  and  the  sphincter  toward 
the  coccyx,  to  secure  the  most  perfect  drainage  possible. 
A  tube  and  packing  are  placed  in  the  incision. 

FISTULA. 
After  having  thoroughly  dilated  the   sphincter  a  blunt 
director  is  passed  from  without  till  its  point  is  felt  within 
the  rectum,  or  if  no  aperture  exists  it  is  thrust   through 
the  mucous  membrane  where  the  least  tissue  intervenes. 

The  point  is  then  pulled  down  out  of  the  rectum,  or,  if 
this  i-  impossible,  the  anus  is  held  open  with  a  speculum, 
1  Annals  Surg.,  1894,  Vol.  XIX..  p.  612. 


44£  ABDOMINAL  WALL  stomach,  AND  INTESTINES. 

and  the  parts  on  the  director  divided  at  right  angles  to  the 
anal  margin.  If  there  is  no  external  orifice,  the  director 
is  bent  to  a  sharp  angle  and  passed  with  the  assistance  of 
the  speculum  from  the  internal  opening,  the  skin  incised 
on  its  point  and  the  parts  on  the  director  cut  as  before. 
Sinuses  in  all  directions  must  be  slit  up  and  granulations 
scraped  away.  Multiple  fistula?  should  be  opened  into 
each  other  if  possible,  and  if  more  than  a  single  complete 
division  of  the  sphincter  is  necessary  one  division  should 
be  allowed  to  heal  before  the  next  is  made.  In  women 
the  sphincter  decussates  in  front  with  the  sphincter  vagina1 
and  cannot  be  completely  divided  at  this  point  without 
considerable  loss  of  power. 

HEMORRHOIDS. 

Ligation, — Concerning  the  treatment  of  hemorrhoids  by 
ligation  there  are  a  few  points  which  deserve  mention. 
The  sphincter  should  be  temporarily  paralyzed  by  forcible 
dilatation.  Every  pile  that  is  more  than  half  an  inch  in 
diameter  must  be  transfixed  by  a  needle  carrying  a  double 
ligature,  and  then  strangulated  by  tying  it  at  its  base  ;  the 
smaller  piles  do  not  need  to  be  transfixed,  it  is  sufficient 
to  throw  a  single  ligature  about  each.  When  the  tegu- 
mentary  margin  would  be  included  in  the  ligature  it  should 
be  cut  through  it  with  scissors.  The  ends  of  the  ligatures 
should  not  be  cut  off'  as  soon  as  they  are  tied,  but  after 
three  Or  four  have  been  placed  at  opposite  points  of  the 
circumference,  it  will  be  found  easy  to  get  an  excellent 
view  of  the  interior  by  drawing  them  outward  and  apart. 

Whitehead's  Operation.* — The  sphincter  is  well  dilated, 
and  the  mucous  membrane,  stalling  posteriorly,  is  divided 
at  its  junction  with  the  skin  by  blunt-pointed  scissors 
around  the  entire  circumference  of  the  bowel.  It  is  dis- 
sected up  with  the  dilated  veins  to  the  interna!  sphincter,  or 
till  all  the  pile-bearing  mucous  membrane  is  drawn  outside 
of  the  anus.  The  mucous  membrane  is  then  divided 
transversely  by  short  snips  of  the  scissors  close  to  its  still 
attached  upper  border,  and  each  pari  as  it  is  cut  is  sutured 
1  British  Medical  J mil.  1887,  Vol  [.,  p.  449. 


EXCISION  OF  ANUS  AND   PART  OF  UECTUM.    449 

to  the  edge  of  the  skin.      The  vessels  are  secured  as  they 
are  divided. 

EXCISION  OF  THE  ANUS  AND  PART  OF  THE  RECTUM. 

This  operation  may  be  rendered  necessary  by  disease 
otherwise  incurable.  The  resulting  condition  is  seldom 
satisfactory,  owing  to  the  loss  of  the  sphincter  if  the  anus 
is  excised,  and  its  almost  certain  paralysis  from  injury  to 
the  nerves  during-  the  manipulation,  if  the  anus  is  left.  It 
must  be  remembered  that  the  peritoneum  descends  upon 
the  anterior  surface  of  the  rectum  to  within  about  an  inch 
of  the  prostate,  but  not  quite  so  far  upon  the  sides  or  be- 
hind ;  its  average  distance  from  the  anus  is  from  two  to 
two  and  one-half  inches  in  front  and  five  inches  behind. 
If  the  upper  limit  of  the  tumor  on  the  posterior  side  can- 
not be  reached  by  the  end  of  the  finger  introduced  through 
the  anus,  its  removal  should  not  be  attempted  from  below. 
The  nature  and  extent  of  its  connections  xvith  the  impor- 
tant organs  on  the  anterior  surface  must  also,  of  course,  be 
carefully  determined. 

A.  Removal  from  below  of  the  Anus  and  Part  of  the 
Rectum. — Two  curved  incisions,  meeting  in  front  and  be- 
hind in  the  median  line,  are  made  through  the  skin,  one 
on  each  side  of  the  anus,  and  at  a  distance  of  about  one 
inch  from  it.  They  are  carried  down  to  the  rectum,  re- 
maining of  course,  external  to  the  neoplasm  if  it  has 
broken  through  the  rectal  wall,  and  the  rectum  is  then 
dissected  upward  as  far  as  necessary,  using  the  ringers  in- 
stead of  the  knife  for  this  purpose  whenever  possible. 
A  sound  should  be  introduced  into  the  bladder  as  a  guide 
if  the  patient  is  a  man,  and  a  finger  into  the  vagina  if  the 
patient  is  a  woman.  When  the  upper  limit  of  the  tumor 
is  reached,  the  rectum  is  drawn  well  down,  its  posterior 
wall  divided  longitudinally,  and  the  diseased  portion 
removed. 

If  the  disease  extends  upward  more  than  one  and  a- 
half  inches,  it  is  advisable  to  prolong  the  incision  back- 
ward to  the  tip  of  the  coccyx,  and  perhaps  even  along 
the  side  of  this  bone. 


450  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

Velpeau  took  the  precaution  to  pass  a  number  of 
threads  through  the  intestine  above  the  proposed  line  of 
excision,  bringing  them  out  through  the  skin  beyond  the 
external  limits  of  the  disease.  After  the  removal  of  the 
tumor,  he  had  only  to  tighten  and  tie  these  threads  to 
bring  the  edges  of  the  incisions  through  the  intestine  and 
the  skin  together. 

Richard  Volkmann  !  lias  modified  this  operation  some- 
what and  claims  that  by  thorough  drainage  and  the  strict- 
est attention  to  disinfection  of  the  wound  during  and  after 
the  operation,  excision  of  the  rectum  can  be  carried  to  a 
very  considerable  height,  and  even  the  peritoneal  cavity 
opened,  without  danger  to  the  patient.  He  empties  the 
bowel  thoroughly,  makes  a  circular  incision  about  the 
anus,  a  straight  one  in  the  median  line  back  from  the  cir- 
cular one  to  the  coccyx,  and,  if  necessary,  another  in  the 
median  line  of  the  perineum  ;  the  bowel  itself  must  not 
be  cut  into.  He  then  draws  the  rectum  down,  dissects  it 
out  circularly  to  the  necessary  height,  passes  ligatures 
through  the  healthy  portion  after  Yelpeau's  plan,  and  cuts 
off  the  lower  portion  containing  the  tumor.  Bleeding 
points  are  temporarily  secured  by  self-retaining  forceps, 
and  afterward  with  eatgnt. 

If  the  peritoneal  cavity  is  opened,  a  sponge  sterile  or 
wet  with  an  antiseptic  solution  is  kept  pressed  against 
the  opening,  until  the  excision  is  completed  ;  then  if  the 
opening  is  -mall  i t -  edges  are  drawn  out  with  artery  for- 
ceps, and  a  ligature  thrown  around  it  as  if  it  was  a  ves- 
sel ;  if  it  is  large,  it  is  closed  with  catgut  sutures. 

The  upper  end  of  the  gut  is  then  drawn  down  and  fast- 
ened to  the  -kin  very  accurately  with  alternate  deep  and 
superficial  sutures,  two  or  three  drainage  tubes  are  in- 
serted, en!  off  close  to  the  surface,  and  stitched  fast. 

During  the  operation,  the  bleeding  surface  is  constantly 
protected  againsi  infection  by  irrigation  with  an  antiseptic 
solution,  and  for  the  firsl  three  or  four  days  constant 
antiseptic  irrigation  is  kepi  up  through  a  tube  passed  well 

1  Uebei  den  Mastdarmkreba  nnd  *  I  i  *  -  Exstirpatio  recti  in  Klinischer 
Vortrage,  No.  13]  (Chirurgie,  No,  42),  p.  111:;.  13th  March,  1878, 


EXCISION  OF  ANUS  AND   PART  OF  RECTUM.   451 

into  the  wound  near  one  of  the  drainage  tubes  ;  daily 
antiseptic  injections  are  afterward  made  through  the  drain- 
ace  tubes  until  the  wound  lias  healed. 

Volkmann  claims  that  these  precautions  strictly  carried 

out  insure  the  patient  against  the  chief  danger  of  the 
operation,  that  of  exciting  diffuse  pelvic  cellular  inflam- 
mation, which  spreads  rapidly  upward  behind  the  peri- 
toneum, and  causes  death  by  sepsis.  Although  the  bleed- 
ing during  the  operation  is  very  severe,  he  has  never 
known  it  to  have  fatal  consequences. 

He  thinks,  also,  that  cancer  is  much  less  likely  to  re- 
turn locally  after  excision  of  the  anus  than  it  is  when  the 
sphincters  are  preserved,  and,  therefore,  he  prefers  total 
excision  of  the  anus  and  of  the  rectum  to  the  upper  limit 
of  the  disease,  even  when  the  anus  itself  is  not  involved. 

B.  Resection  of  the  Rectum  from  below,  leaving  the 
Sphincter. — After  thoroughly  emptying  the  bowels  in  ad- 
vance the  patient  is  placed  in  the  lithotomy  position,  or 
on  the  side  with  the  hips  and  knees  flexed.  An  incision 
is  made  in  the  median  line  posteriorly  through  the  anus 
and  rectal  wall  below  the  disease,  and  carried  to  the  coc- 
cyx. With  a  sound  in  the  urethra  or  finger  in  the  va- 
gina, another  incision  in  the  median  line  in  front  is 
carried  through  the  anus  and  lower  healthy  rectal  wall 
into  the  perineum.  The  buttocks  are  separated  and  the 
lips  of  these  incisions  drawn  apart  with  blunt  retractors. 

The  sound  rectum  is  then  divided  transversely  below 
the  disease  and  above  the  sphincter  by  lateral  incisions 
joining  the  upper  extremities  of  the  incisions  through  its 
anterior  and  posterior  walls.  By  working  with  the  fingers 
and  blunt-pointed  scissors  from  within  outward  through 
the  transverse  incisions  in  the  rectal  wall,  the  diseased 
rectum  above  is  separated  all  around  on  its  outer  surface 
from  the  surrounding  tissues  and  drawn  down.  The  ves- 
sels are  tied  as  they  are  cut,  but  if  the  dissection  is  made 
mostly  by  tearing  with  the  fingers  the  greater  part  of  the 
hemorrhage  can  be  arrested  by  pressure.  A  temporary 
suture  with  the  ends  left  long  is  then  passed  through  the 
anterior  and  posterior  walls  of  the  rectum  above  to  pre- 


452    ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

vent  it-  retraction,  while  the  diseased  part  is  excised  by 
a  transverse  division  of  the  bowel  in  the  healthy  tissue 
below  tlic  retention  sutures. 

The  <-ut  ends  of  the  rectum  are  united  all  around  by  in- 
terrupted sutures  passed  with  a  sharply  curved  needle,  and 
then  the  incisions  in  its  anterior  and  posterior  walls.  A 
large  drainage  tube  surrounded  by  light  packing  and  reach- 
ing above  the  point  of  division  is  placed  in  the  rectum, 
the  wounds  in  the  perineum  and  behind,  including  the 
sphincter,  are  closed  with  dee])  sutures  and  a  drainage 
tube  placed  in  the  lower  angle  of  each. 

Fig.  21-"). 


Resection  of  the  rectum,  showing  Bueter's  curved  incision.    The  straight  Incision 
i-  thai  I'M  posterior  rectotomy. 

C.  Hueter's  Operation  by  a  Perineal  Flap.  (Fig.  215.) — 
The  patient  occupies  the  lithotomy  position  and  a  sound 
i-  introduced  into  the  urethra.  A  Hap,  including  the 
anus  and  adjoining  part  of  the  perineum,  is  marked  out 
of  an  inverted  U-shape,  having  the  anus  a  little  in  front 
of  the  eent<  r  of  the  base,  which  is  posterior.  To  form 
thi-  an  incision  is  made  through  the  skin  and  subcu- 
taneous tissue, starting  al  the  level  of  the  posterior  end  of 
the  tuber  ischii  outside  of  the  outer  border  of  the  sphinc- 
ter ani,  passing  forward  and  crossing  the  perineum  close 
t<>  the  posterior  insertion  of  the  scrotum,  then  backward 
to  terminate  on   the  other  side  of  the  anus  outside  the 


EXCISION  OF  ANUS  AND  PART  OF  RECTUM.    153 

sphincter   opposite    the   starting    point.     The  incision   is 
deepened;    and    anteriorly,    in   the    bend  of  the  U,    the 

junction   of  the  accelerator   iirinse   with    the    compressor 
urethra?  muscles  cul  through,  and  the  flap  including  the 

sphincter  ani  turned  down. 

Working  in  from  in  front  the  reef  inn  is  isolated  on  all 
sides  and  the  diseased  portion  excised  by  transverse  divis- 
ion of  the  bowel  through  healthy  tissue  above  and  below 
the  disease.  The  bleeding  in  this  large  wound  is  stopped 
by  ligation  or  pressure. 

The  cut  ends  of  the  rectum  are  brought  together  all 
around  with  sutures,  and  the  flap  replaced,  with  a  drain 
and  light  packing  in  each  lower  angle.  A  tube  and  pack- 
ing reaching  above  the  line  of  division  is  then  inserted 
through  the  anus.  The  mucous  membrane  might  first  be 
united  by  a  separate  row  of  sutures  not  entering  the  mus- 
cular coat,  which  is  afterward  brought  together  by  sutures 
of  catgut  penetrating  the  muscular  coat  alone,  so  as  to  bring 
the  suture  line  in  the  mucosa  below  that  in  the  muscularis 
and  thus  make  communication  less  easy  for  the  feces  from 
the  interior  of  the  bowel  to  the  perirectal  tissue.  Zucker- 
kandl's  method  for  reaching  the  seminal  vesicles  (</.  r.)  is 
very  similar  to  this  operation. 

D.  Resection  of  the  Rectum  from  behind  (Kraske's 
Operation)  with  Removal  of  the  Coccyx  and  part  of  the 
Sacrum.1 — The  patient  is  placed  on  the  right  side  and  an 
incision  is  made  in  the  median  line  from  the  middle  of  the 
sacrum  to  the  anus  and  carried  down  to  the  bone.  The 
fibers  of  the  gluteus  are  detached  from  the  lower  part  of 
the  left  half  of  the  sacrum  and  from  the  coccyx,  and  the 
latter  bone  removed.  The  left  side  of  the  incision  is  then 
drawn  forcibly  aside  and  the  greater  and  lesser  sacrosciatic 
ligaments  successively  divided  close  to  their  attachment  to 
the  sacrum.  This  gives  access  to  a  large  portion  of  the 
rectum,  but  if  more  room  is  desired  it  can  be  obtained  by 
chiseling  away  the  lower  left  part  of  the  sacrum  below 

1  Ardi.  f.  klin.  Chir.,  1886,  Vol.  XXXIII..  p.  566.  For  a  review 
of  this;  operation  and  its  modifications,  sec  Frank  :  Wien.  klin.  Wbch., 
18U1,  Vol.  IV..  [>.  Siio. 


454  ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 

the  third  sacral  foramen  and  including  the  fourth  without 
opening  the  sacral  canal.  The  anterior  branches  of  the 
fourth  and  fifth  sacral  nerves  arc  necessarily  divided  in 
this  procedure. 

The  posterior  branches  and  the  fifth  nerve  are  of  no 
importance,  but  the  nerve-supply  of  the  levator  ani,  coc- 
cygeus,  and  sphincter  anion  the  left  side  is  of  course  cut  off. 

Hochenegg's  modification  of  the  bone  removal  is  rep- 
resented in  Fig.  21 G. 

Bardenheuer  still  further  modified  it  by  the  removal  of 
all  the  sacrum  below  the  third  sacral  foramen,  which  de- 
stroys the  possibility  of  subsequent  restoration  of  the  func- 
tion of  the  sphincter. 

The  rectum  is  now  freed  by  division  of  the  connective 
tissue  binding  it  to  the  sacrum,  and  drawn  downward  so 
far  as  may  be  necessary  to  bring  the  subsequently  cut  ends 
of  the  gut  into  apposition  without  undue  tension  on  the 
sutures.  To  give  more  room  and  greater  protection  to 
the  important  male  organs  lying  close  in  front  of  the 
rectum,  the  sphincter  and  rectal  wall  from  the  anus  up  to 
the  tumor  can  be  cut  posteriorly  in  the  median  line;  but 
it  is  not  always  necessary. 

The  growth  is  then  freed  by  the  finger  and  blunt- 
pointed  scissors  from  its  lateral  and  anterior  connections 
and  excised  with  a  margin  of  healthy  tissue,  by  transverse! 
division  of  the  rectum  above  and  below. 

If  the  relations  of  the  tumor  make  it  necessary,  the 
peritoneal  cavity  must  be  opened  and  involved  portions  of 
the  peritoneum,  together  with  any  glands  which  can  be 
felt,  removed  with  the  tumor.  The  peritoneum  is  then 
drawn  together  with  line  catgut  sutures  and  secured 
against  infection  l>v  an  iodoform-gauze  packing.  The 
anterior  half  of  the  divided  bowel  is  united  by  silk  su- 
ture- through   its  mucous  and   muscular  coats,  while  the 

posterior  half  i.-  left  open  and,  if  possible,  sutured  to  the 

-kin  :it  the  margins  of  the  wound;  it  can  afterward  he 
closed  by  n  secondary  operation. 

[f  the  anus  and  adjacent  rectal  wall  have  been  split 
posteriorly,  the  rectal   part  of  the  wound  is  closed  l>v  in- 


EXCISION  OF  ANUS  AND  PART  OF  MECTUM.    155 

terrupted  catgut  sutures  and  the  sphincter  drawn  together 

by  (Iccp  silk  or  silver-wire  sutures  passed  in  the  manner 

described  for  restoring  a  completely  ruptured   perineum. 

The  overlying  parts  and  the  upper  and  lower  angles  of 


Fig.  216. 


\ZUppcr  half  of  fiffh 

j,     posterior  sacral  foramen. 


Resection  of  the  rectum  from  behind.    A.  It.  Portion  of  the  sacrum  removed  in 
Kraske's  operation.     A.  ('.  Hoehenegg's modification. 

the  posterior  wound  arc  drawn  together  with  silk  sutures, 
and  a  drainage  tube  and  packing  placed  in  each  angle. 
The  center  of  the  wound,  with  the  open  half  of  the  rec- 
tum, is  packed  and  a  drainage  tube  passed  into  the  bowel 


156  ABDOMINAL   WALL.  STOMACH,  AND  INTESTINES. 

above.  Afterward  the  patient  will  have  to  be  kepi  on  a 
water-bed. 

A  colotomy  performed  a  week  or  two  before  this  oper- 
ation is  of  great  assistance  in  keeping  the  wound  aseptie 
and  avoiding  the  very  frequent  and  early  dressings  other- 
wise necessary. 

Heineke  recommends  an  [_-shaped  incision  from  the 
anus  to  the  coccyx,  then  along  the  left  border  of  the 
sacrum  up  to  the  fourth  sacral  foramen,  and  then  trans- 
versely to  the  right  border  of  the  sacrum.  The  bone  is 
chiseled  through  in  this  line  and  the  flap]  turned  down 
and  to  the  right.  Rydygier  dispenses  with  the  trans- 
verse incision  in  the  skin. 

Levy  divides  the  sacrum  transversely  a  finger's  breadth 
above  its  lower  extremity,  and  from  each  end  of  the  trans- 
verse  incision  carries  one  downward  toward  the  ischial 
tuberosities,  the  soft  parts  attached  to  the  side  of  the  sa- 
crum below  its  point  of  transverse  division  are  cut,  and  the 
bone-and-skin  flap  turned  down. 

Hegar  employs  a  V-*l>:ipe(l  incision  starting  at  the  pos- 
terior inferior  spines  of  the  ilia  and  following  the  sides  of 
the  sacrum  to  the  tip  of  the  coccyx.  The  periosteum  is 
separated  from  the  anterior  surface  of  these  bones  ;  the 
sacrum  sawed  transversely  and  turned  up. 

Almost  any  of  these  methods  of  operation  gives  access 
to  the  female  pelvic  organs. 

LIVER. 
Anatomy. — The  level  of  the  upper  surface  of  the  liver 
is  indicated  by  a  line  drawn  through  the  fifth  ehondro- 
sternal  articulation  on  the  right  side  and  through  the 
-i\ih  mi  the  left.  It  is  uncovered  by  the  ribs  where  it 
crosses  the  subcostal  angle,  from  the  ninth  righi  to  the 
eighth  li'ft  costal  cartilage.  The  lefl  lobe  extends  one 
and  a-half  !<»  two  indies  beyond  the  left  margin  of  the 
sternum.  The  lung  descends  over  the  upper  surface  of 
the  diaphragm  and  liver  on  the  right  side  to  the  lower 
border  of  the  sixth  rib  in  the  mammary  line,  in  the  mid- 
:i  \ ilia rv  line  to  i  he  upper  border  of  t  he  eighth  rib,  and  in 


LIVER.  4:>7 

the  scapular  line  to  the  upper  border  of  the  tenth  rib. 
The  pleura  descends  about  lialt*  an  inch  lower,  following 
the  costo-chondral  junction,  or  the  bony  extremities  of  the 

ribs,  and  the  lower  border  of  the  eleventh  rib.  As  the 
twelfth  rib  is  sometimes  very  short,  it  may  be  overlooked. 
Therefore  the  ribs  should  be  counted,  and  the  lower  edge 
of  the  pleura  will  be  found  passing-  horizontally  from  the 
lower  border  of  the  twelfth  dorsal  vertebra  to  the  lower 
border  of  the  eleventh  rib. 

The  gall-bladder  is  about  four  inches  long  and  an  inch 
wide,  and  normally  holds  about  an  ounce.  Its  fundus 
touches  the  abdominal  wall  immediately  below  the  ninth 
costal  cartilage  near  the  outer  border  of  the  right  rectus 
muscle.  The  cystic  duct  is  about  an  inch  long,  and  the 
common  duct  three  inches  long.  The  latter  descends  in 
the  right  border  of  the  lesser  omentum  behind  the  first 
portion  of  the  duodenum,  in  front  of  the  portal  vein  and 
to  the  right  of  the  hepatic  artery  ;  it  then  passes  between 
the  pancreas  and  duodenum,  behind  the  pancreatico-duo- 
denalis  artery,  to  empty  into  the  middle  of  the  inner  side 
of  the  second  portion  of  the  duodenum. 

Abscess  of  the  Liver. — An  incision,  preferably  longi- 
tudinal, three  or  four  inches  long  is  made  over  the  most 
prominent  part  of  the  tumor  below  the  ribs.  The  inci- 
sion is  deepened  to  the  peritoneum,  and  if  the  liver  is 
found  adherent  beneath  this  incision  the  abscess  is  simply 
incised  for  about  an  inch  and  drained  with  a  large  tube, 
and  packing  if  necessary,  bearing  in  mind  the  very  friable 
character  of  the  abscess-walls.  If  the  liver  is  not  adher- 
ent where  the  abdomen  has  been  opened,  but  is  found  to 
be  so  at  some  other  spot  below  the  ribs,  another  incision 
is  made  through  the  parietes  over  this  spot,  and  the  ab- 
scess reached  through  the  safely  adherent  area.  The  first 
incision,  having  served  as  a  guide,  is  closed  in  the  usual 
way  and  well  protected  from  infection  before  the  abscess 
is  opened. 

If  the  abscess  must  be  opened  immediately,  and  there 
are  no  adhesions  to  the  parietal  peritoneum,  a  sponge 
packing  is  inserted  to  protect   the  rest  of  the  abdominal 


t58    ABDOMINAL  WALL.  STOMACH,  AND  INTESTINES. 

cavity,  and  the  point  of  an  exploring-needle  buried  in  the 
liver.  The  piston  is  immediately  withdrawn  and  the 
medic  slowly  pushed  on  in  a  straight  line.  By  with- 
drawing the  piston  as  soon  as  possible  pus  will  flow  into 
the  cylinder  when  it  is  first  reached,  and  by  pushing  the 
needle  always  in  a  straight  line  unnecessary  and  easily-in- 
flicted  damage  to  the  gland  is  avoided.  If  the  first  ex- 
ploration fail,  the  needle  must  be  taken  out  and  reinserted 
in  different  straight  directions  till  pus  is  found. 

With  the  needle  as  a  guide,  a  knife  is  then  passed 
through  the  liver-substance  into  the  abscess-cavity,  while 
the  liver  is  kept  in  as  close  contact  with  the  abdominal 
wall  as  possible,  rolling  the  patient  on  one  side  if  neces- 
sary. The  index-finger  is  quickly  passed  along  the  track 
of  the  knife  and  the  opening  enlarged  to  an  inch  or  more 
and  hooked  up  without  force  into  the  abdominal  wound. 
Hemorrhage  is  controlled  by  packing.  After  the  pus  has 
been  evacuated,  the  interior  or  the  abscess-cavity  is  irri- 
gated with  warm  boiled  water  ;  its  opening  is  then  plugged 
with  a  sponge,  and  the  parietal  peritoneum  and  the  skin 
around  the  margins  of  the  abdominal  wound  are  united 
with  catgut.  After  removal  of  the  protective  packing 
from  the  abdomen  the  liver  is  fastened  in  the  wound  by 
interrupted  catgut  or  fine  silk  sutures  passed  through  its 
substance  at  a  little  distance  outside  of  the  abscess-opening, 
i"  -hut  off  its  communication  with  the  general  peritoneum. 

If  the  stitches  show  a  tendency  to  tear  out,  sterilized 
gauze  must  be  packed  around  the  opening  in  the  liver  ami 
the  cuds  brought  out  of"  the  abdominal  wound. 

The  sponge  plug  is  then  removed  and  a  large  drainage 
tube  inserted,  [mmediately  before  incising  the  liver  an 
attempt  can  be  made  to  unite  the  parietal  and  visceral 
peritoneum  with  catgut  sutures  around  the  proposed  area 
of  the  incision,  lint  the  stitches  may  tear  out  or  puncture 
and  cause  leakage  from  the  abscess  into  tin-  general  peri- 
toneal cavity.  A-  the  liver  ascends  and  descends  with 
respiration  it  cannot   be  fastened  to  the  abdominal  wall  at 

a  less  distance  than  half  an  inch  from  the  free  border  of 
l  lie  nli-  and  COStal  cartilage-. 


HYDATID  CYST  OF  THE  LIVER.  459 

Whenever  there  is  time  it  is  always  best  to  secure  firm 
adhesions  of  the  liver  to  the  parietes  in  the  selected  region 
before  evacuating-  the  pus.  A  longitudinal  incision  two 
or  three  inches  long  is  carried  down  layer  by  layer  and  the 
peritoneum  opened  and  the  liver  exposed.  After  carefully 
protecting  the  surrounding  viscera  with  sponge,  the  pres- 
ence of  pus  is  verified  with  a  fine  aspirating  needle,  and 
the  point  of  puncture  is  then  covered  with  an  iodoform - 
gauze  packing  large  enough  to  hold  the  margins  of  the 
abdominal  wound  apart  and  in  contact  with  the  liver.  In 
addition,  the  parietal  peritoneum  and  skin  can  be  united 
with  catgut  around  the  margins  of  the  incision.  A  fairly 
tight  antiseptic  dressing  is  applied,  and  in  the  course  of 
two  or  three  days  adhesions  will  have  shut  off  the  abdom- 
inal cavity  and  the  abscess  can  be  safely  opened  without 
an  anaesthetic. 

It  is  generally  unwise  to  approach  an  abscess  of  the 
liver  through  the  thoracic  cavity;  but  if  unavoidable,  the 
selected  intercostal  space  should  be  enlarged  by  resection 
of  a  rib,  and  the  layers  of  the  parietal  and  diaphragmatic 
pleura  carefully  united  with  catgut  sutures  around  the 
proposed  line  of  drainage.  The  surface  of  the  liver  is 
then  exposed  by  an  incision  through  the  diaphragm  and 
the  future  drainage  track  packed  with  iodoform  gauze  till 
adhesions  have  formed. 

If  the  liver  and  diaphragm  are  already  adherent,  the 
abscess  can  be  opened  immediately,  provided  the  pleural 
cavity  is  secured  from  infection. 

It  is  unsafe  to  aspirate  a  possible  abscess  of  the  liver 
through  the  unopened  abdominal  or  thoracic  wall. 

HYDATID  CYST  OF  THE  LIVER. 
The  operative  treatment  of  hydatid  cyst  of  the  liver  is 
almost  identical  with  that  of  abscess.  After  partial  evac- 
uation of  its  contents  by  a  trocar  and  canula  or  aspirating 
needle  the  cyst  wall  can  be  more  readily  drawn  into  the 
abdominal  wound  and  sutured  there,  and  thus  the  rest  of 
the  abdominal  cavity  is  more  effectually  protected  than  in 
the  case  of  an  abscess,  and  a  cyst  can  be  more  safely 
opened  immediately. 


460   ABDOMINAL   WALL,  stoma  elf,  AND  INTESTINES. 

Cholecystectomy.  (Fig.  217.) — An  incision  three  or 
lour  inches  long  is  made  vertically  downward  from  the 
lower  border  of  the  liver  opposite  the  tip  of  the  cartilage 

of  the  tenth  rib,  and  deepened  layer  by  layer  and  the 
peritoneum  opened.  If  an  extensive  dissection  or  an 
operation  on  the  cystic  or  common  duct  is  anticipated 
more  room  will  be  needed,  and  it  is  better  to  use  an  in- 
cision about  four  inches  long,  starting  from  the  median 
line  an  inch  below  the  ensiform  process,  extending 
obliquely  downward  and  outward,  and  terminating  hori- 
zontally.     If  the  liver  is  enlarged   the  oblique  incision 


[ncisions  for  exposing  the  gall-bladder. 

should  follow  a  line  parallel  to  and  just  above  its  free 
border. 

Bevan  '  recommends  a  F-shaped  incision,  the  central 
portion  of  which  lies  beside  the  rectus,  while  the  upper 
end  curves  partly  across  the  rectus  about  three-quarters 
of  :iu  inch  from  the  costal  border,  and  lower  portion 
curves  outward  at  about  the  level  of  the  umbilicus.  He 
claims  that  while  this  gives  ample  exposure  it  largely 
spares  the  nerve-supply  of  the  rectus. 

When  a  distended  gall-bladder  is  encountered  it  is  care- 
fully surrounded  with  a  protective  sponge  packing  and 
1  Anna]*  of  Surg.,  July.  L899. 


HYDATID  CYST  OF  THE  LIVER.  461 

enough  fluid  drawn  off  with  an  aspirator  to  allow  the 
walls  thus  relaxed  to  be  pinched  up  on  each  side  of  the 
needle  by  the  fingers  or  padded  forceps  and  drawn  into 
the  abdominal  wound.  Sponges  are  wedged  around  it  to 
prevent  leakage  into  the  peritoneum,  and  the  fluid  is 
evacuated  by  a  trocar  and  canula,  or  a  knife  plunged  into 
the  bladder  wall  at  the  point  of  puncture  made  by  the 
needle.  In  selecting  this  point  of  puncture  allowance 
must  he  made  for  retraction  of  a  distended  bladder.  If 
the  bladder  is  not  distended,  a  finger  is  passed  along  its 
inner  surface  following  the  cystic  and  common  duct,  to 
explore  for  the  trouble  as  far  as  the  intestine.  A  careful 
dissection  with  the  finger  nail  and  blunt-pointed  scissors 
may  be  necessary  to  separate  adhesions  to  surrounding 
viscera  and  even  to  find  the  gall-bladder. 

After  protecting  the  rest  of  the  abdominal  cavity  with 
a  sponge  packing  the  fundus  of  the  bladder  is  drawn  as 
far  as  possible  into  the  abdominal  wound  and  opened 
enough  to  admit  one  finger.  All  stones  are  then  gently 
scooped  or  irrigated  out,  the  abdominal  wound  partly 
closed  in  the  usual  way,  and  the  protective  sponges  re- 
moved. The  gall-bladder  is  fastened  in  the  wound  by  a 
continuous  silk  suture  passed  through  the  skin,  perito- 
neum, and  the  whole  thickness  of  the  bladder  wall  around 
the  margin  of  the  opening  in  it.  The  suture  line  must 
be  far  enough  away  from  the  fret'  border  of  the  ribs  to 
allow  for  the  respiratory  movements  of  the  liver. 

A  large  rubber  drainage  tube  is  passed  into  the  fistu- 
lous opening  and  an  abundant  absorbent  dressing  applied 
which  will  need  frequent  renewal.  It  is  not  advisable  to 
close  a  wound  of  the  gall-bladder  by  the  Czerny-Lembert 
method  of  suture  and  leave  no  communication  with  the 
parietal  incision. 

Operations  Involving  the  Cystic  or  Common  Bile  Duct. 
(Fig.  217.) — The  oblique  incision  is  used,  or  the  vertical 
changed  later  if  necessary  into  a  crucial  or  J-shaped  in- 
cision. After  locating  the  stone  by  the  exploring  finger 
and  protecting  the  rest  of  the  abdomen  by  a  spouge-pack- 
ing,  an  attempt  is  made  to  manipulate  the  calculus  buck 


462  ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 

into  the  bladder  or  forward  into  the  intestine,  but  bear- 
ing in  mind  that  the  duets  are  easily  lacerated  and  very 
slightly  distensible. 

If  it  seem  feasible  to  reach  the  stone  from  the  interior 
of  the  gall-bladder,  this  viseus  is  opened  in  the  manner 
already  described,  and  one  of  the  specially  devised  chole- 
lithotomy  forceps  used  to  clip  or  nibble  the  stone  into 
fragments,  guided  by  the  other  hand  in  the  abdomen. 
The  operation  is  completed  as  described  for  cholecyst- 
ostomy.  On  the  same  principle  an  impacted  calculus  has 
been  crushed  by  padded  forceps  applied  to  the  exterior  of 
the  duct,  and  has  been  broken  by  the  point  of  an  aspir- 
ating needle  puncturing  the  duet.  Dr.  McBurney  ex- 
tracted one  after  splitting  the  distal  portion  of  the  duct 
through  an  opening  made  in  the  duodenum  for  the  pur- 
pose. For  a  stone  otherwise  irremovable  from  the  cystic 
duct  cholecystectomy  is  preferable  to  needling  or  crushing 
externally  with  padded  forceps.  But  there  must  be  no 
doubt  about  the  patency  of  the  common  duct. 

For  a  calculus  impacted  below  the  cystic  duct,  the  ob- 
lique abdominal  incision  is  used  and  the  surrounding  vis- 
cera  arc  well  protected  and  retracted  by  a  sponge  packing. 
The  duct  is  opened  in  its  long  axis  over  the  stone  suffi- 
ciently to  extract  the  latter,  and  the  opening  then  closed 
by  interrupted  Czerny-Lembert  sutures,  which  because  of 
the  generally  increased  thickness  of  the  duct  wall  from  the 
irritation  caused  by  the  presence  of  the  calculus  is  not 
very  difficult.  A  drainage  tube  and  iodoform  gauze 
packing  is  carried  from  the  abdominal  wound  down  to 
the  neighborhood  of  the  suture  line  and  the  abdominal 
wound  partly  closed  in  the  usual  way. 

W  an  opened  gall-bladder  must  be  sutured  in  the  ab- 
dominal wound  ;it  the  same  time,  its  opening  must  be 
separated  as  far  as  possible  from  the  drainage  tube  by  in- 
termediate suturing. 

CHOLECYSTENTEROSTOMY. 

Tlii-  term  is  used  to  designate  the  establishment  of  a 
permanent  fistulous  communication  between  the  gall-bind- 


t 'HOLECTSTENTEROSTOMT.  463 

derand  the  intestine.  The  operation  is  designed  to  create 
a  nmte  by  which  the  bile  can  pass  into  the  intestine  when 
the  common  duet  is  permanently  obstructed,  and  when 
both  the  cystic  and  hepatic  duets  are  patent  and  com- 
municate, and  for  some  cases  of  persistent  biliary  fistula. 
The  abdomen  is  opened,  preferably  by  the  vertical  in- 
cision, and  a  convenient  loop  of  intestine  as  near  the  duo- 
denum as  possible  is  isolated  by  iodoform-gauze  bands 
tied  around  the  gut  above  and  below,  and  to  this  isolated 
loop  the  gall-bladder  is  sutured  and  the  communication 
established  in  the  same  manner  as  described  for  intestinal 
anastomosis. 

The  bladder  is  first  emptied  by  an  aspirating  needle 
entered  as  near  as  possible  to  the  site  of  the  future  fistula. 
A  continuous  fine  silk  suture  is  passed  uniting  the  serous 
coats  of  the  bladder  and  the  intestine  at  the  convex  free 
border  of  the  latter  for  a  distance  of  about  an  inch  and  a- 
half,  and  in  front  of  this,  as  the  parts  lie  exposed,  a  row 
of  Lembert  sutures  is  inserted.  After  carefully  protect- 
ing the  surrounding  parts  by  a  fresh  sponge  packing,  the 
opposing-  surfaces  of  the  gall-bladder  and  intestine  are 
opened  longitudinally  for  about  an  inch  close  in  front  of 
the  Lembert  sutures,  and  the  interior  of  each  irrigated 
clean.  The  mucous  membranes  are  united  by  a  continu- 
ous fine  silk  or  catgut  suture,  and  a  row  of  Lembert 
sutures  continuous  with  those  already  in  place  completes 
the  serous  apposition  all  around.  The  gauze  constricting 
bands  and  sponges  are  removed  and  an  iodoform-gauze 
packing  placed  around  the  suture  line  and  the  ends 
brought  out  of  the  abdominal  wound,  which  is  partly 
closed  in  the  usual  way. 

Murphy's  "button"  has  proved  peculiarly  valuable  in 
cholecystenterostomy.  The  button  can  be  made  small 
enough  to  be  easily  passed  otf  by  the  intestine,  and  at  the 
same  time  leave  a  communication  with  the  gall-bladder 
large  enough  to  be  useful  in  spite  of  any  probable  subse- 
quent cicatricial  contraction. 

The  abdomen  is  opened  by  the  vertical  incision,  the 
bladder  is  aspirated,  and  a  -elected   loop  of  intestine   iso- 


1'W    ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

lated  a>  usual,  and  ;i  protective  sponge  packing  placed  in 
tin-  abdomen.  A  "puree-string"  suture  "I'  line  -ilk  i> 
passed  through  the  -emu-  coai  of  the  bladder  and  intes- 
tine enclosing  an  area  on  each  large  enough  to  contain  a 
-lit  the  length  of  the  diameter  of  the  buttons.  The  1  > 1 1 1  — 
tons  are  inserted  in  the  longitudinal  slits  then  made  in 
the  bladder  and  gut,  ami  the  wounds  are  drawn  tight 
around  the  central  cylinder  by  tying  the  sutures.  The 
buttons  are  -imply  pressed  together,  and  the  wounds, 
with  the  suture  in  each,  are  -hut  within  the  concavity 
bounded  by  the  margins  of  the  buttons  holding  the  serous 
surfaces  in  apposition. 

The  calculi  are  not  disturbed,  but  lefl  to  be  defecated 
with  the  button,  and  the  abdominal  wound  is  closed  with- 
out drainage  after  removing  the  -j ges. 

CHOLECYSTECTOMY. 

The  abdomen  is  opened  by  the  oblique  incision  ami  the 
gall-bladder  surrounded  with  sponges.  Starting  at  the 
fundus,  an  incision  is  made  on  each  side  of  the  bladder 
through  the  peritoneum  at  a  little  distance  from  the  liver, 
and  the  bladder  dissected  out  with  blunt-pointed  scissors 
a-  far  a-  the  cystic  duet.  The  latter  i-  divided  between  a 
double  ligature  of  silk,  and  the  peritoneal  Saps  closed  over 
the  liver  by  a  continuous  catgul  suture.  The  abdominal 
wound  is  partly  closed  around  a  tube,  and  light  iodofbrm- 
gauze  packing  carried  down  to  the  former  site  of  the  gall- 
bladder. 

SPLEEN. 

Anatomy.— The  pedicle  of  the  spleen  will  lie  formed  by 
the  gastro-splenic  omentum  passing  from  the  hilum  to  the 
stomach  and.  continuous  with  this  above,  the  suspensory 
ligament  passing  to  the  diaphragm.  The  splenic  arterj 
lie-  above  the  vein  behind  the  upper  border  of  the  pan- 
creas. The  gastro-splenic  omentum  contains  it-  terminal 
or  -i\  branches  which  arise  at  a  variable  distance 
from  the  spleen  and  may  enter  it-  hilum  over  a  consider- 
able area.      Most  of  the  vasa  brcvia  arise  from  these  and 


KIDNE] 

turn  backward  to  the  stomach,  and  near  the  termination 
of  the  main  splenic  artery  the  gastro-opiploicn  sinistra 
i>  given  off.  The  venous  branches  correspond  to  the 
arterial, 

SPLENECTOMY 

A  vertical  incision  three  or  tour  inches  long  is  made 
along  the  outer  border  of  the  left  rectus  muscle  above  the 
umbilicus,  and  the  peritoneum  opened,  [fthe  spleen  has 
prolapsed  into  an  already  existing  wound,  the  latter  ia 
simply  enlarged  ;i>  much  a<  necessary.  Adhesions  art1 
separated  or  divided  between  double  catgut  ligatures,  and 
the  tumor,  which  must  be  very  gently  handled,  is  fully 
exposed.  Alter  surrouuding  it  with  a  sponge  packing  it 
i-  turned  out  of  the  abdominal  wound,  general h  the 
lower  end  first.  The  abdominal  opening  should  be  made 
large  enough  to  allow  the  tumor  to  pass  without  force,  and 
the  margins  of  the  wound  should  he  held  back  to  avoid 
all  traction  on  the  pedicle.  Starting  at  it-  lower  edge, 
successive  pairs  of  artery  clamps  are  applied  to  the  peui 
cle  in  advance  of  the  line  of  division  which  is  then  made 
between  them. 

The    spleen    is    then    removed   and    the   vessels    in    the 

grasp  of  each  clamp  are  ligated  separately  with  silk,  \- 
each  clamp  is  removed  bleeding  point-  are  sought  for  and 
seen  red  :  after  this  Greig  Smith  advises  that  the  whole 
pedicle  be  surrounded  by  a  ligature  drawn  moderately 
tight  to  lessen  the  arterial  pressure  distal  to  it  on  the 
ligatures  of  each  vessel.  The  abdominal  wound  is  then 
closed  tight  in  the  usual  way, 

KIDNEY. 
Anatomy. — 'The  kidney  lies  imbedded  in  fatty  tissue 
which  is  more  abundant  behind  than  in  front]  and  from 
which  it  can  be  easily  enucleated.  Posteriorly  the  upper 
half  rests  against  the  diaphragm  and  the  lower  half  upon 
the  transversalis  aponeurosis,  and  is  crossed  posteriorly 
by  the  last  dorsal,  the  ilio-hypogastrio,  and  ilioinguinal 
nerves.  In  front,  from  above  downward,  the-  liver,  du- 
30 


466  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

odcnum,  and  hepatic  flexure  of  the  colon  arc  in  contact 
with  the  right  kidney  ;  the  stomach  with  the  spleen  ex- 
ternally, the  pancreas  and  descending  colon  are  in  relation 
with  the  anterior  surface  of  the  left  kidney. 

Thus  the  colon  generally  lies  vertically  in  front  of  a 
renal  growth  on  the  right  side,  and  on  the  left  side  crosses 
i(  obliquely  from  above  downward  and  outward.  The 
peritoneum  over  such  a  tumor  can  be  divided  on  the  outer 
side  of  the  colon,  but  not  on  the  inner,  without  interfer- 
ing with  the  blood-supply  of  the  bowel. 

The  renal  artery,  which  may  divide  into  one  or  more 
branches  before  entering  the  hilum,  subdivides  into  ter- 
minal branches,  which  are  said  commonly  to  lie  in  front 
of  the  veins.  The  renal  vein  subdivides  earlier  than  the 
artery,  and  the  left  vein  receives  the  left  spermatic  and 
left  inferior  phrenic  veins  which  are  within  reach  of  in- 
jury during  treatment  of  the  renal  pedicle.  The  vessels 
lie  in  front  of  the  ureter,  which  terminates  near  the  lower 
border  of  the  kidney  in  its  pelvis.  The  latter  subdivides 
in  the  hilum  into  two  or  three  short  trunks  (infundibula), 
which  in  turn  subdivide  into  the  ealices  opening  over 
the  papilla?  ;  so  that  a  finger  cannot  pass  from  the  pelvis 
into  the  first  subdivision  and  much  less  into  the  second  or 
ealices. 

As  the  twelfth  rib  may  be  rudimentary  or  absent  the 
ribs  should  always  be  counted  before  a  lumbar  operation, 
in  order  to  avoid  the  pleura,  which  is  generally  found  to 
pass  horizontally  from  the  lower  border  of  the  twelfth 
dorsal  vertebra  to  the  lower  border  of  the  eleventh  rib. 

EXPOSURE  OF   THE  KIDNEY. 
Lumbar  Methods. — The  patient  lies  upon  the  sound  side 
with  a  sand-bag  under  tin;  loin  to  widen  the  opposite  cx- 
posed  costo-iliac  space. 

A.  Till-:  LONGITUDINAL  [NCISIOK  is  made  along  the 
outer  border  of  the  muscular  mass  formed  by  the  erector 
spina;  and  sacro-lumbaliS;  which  is  about  two  and  a-half 

to  three  inches    from    the  vertebral    spines,  and    it  should 
extend  through  the  skin  from  the  eleventh  rib  to  the  iliac. 


EXP()SrilE   OF   THE   KIDNEY. 


467 


crest.  (Fig.  218.)  It  is  deepened  through  the  middle 
layer  of  the  lumbar  fascia  or  the  aponeurosis  of  the  trans- 
versalis,  and  the  posterior  surface  of  the  quadratus  lum- 

boruni  is  exposed.  The  outer  border  of  the  muscle  is 
cleared  and  drawn  toward  the  spine,  and  after  retraction 
of  the  sides  of  the  wound,  the  peri-renal  fat  can  usually 

he  seen  through  the  thin  anterior  layer  of  the  lumbar 
fascia,  moving  synchronously  with  respiration.  Space 
can  l>e  advantageously  gained  by  dividing  the  outer  por- 
tion of  the  quadratus  close  to  its  attachment  to  the  ilium. 


Fig.  218. 


UK1 


Incision  for  exposing  the  kidney.      L.    Longitudinal  or  vertical  incision. 
Transverse  or  oblique  incision.     K.   Konig's  incisioD. 


T. 


On  division  of  the  thin  intervening  fascia  the  fatty  cap- 
sule of  the  kidney  is  reached,  and  by  tearing  through  it 
and  stripping  it  toward  the  sides  the  posterior  surface  of 
the  middle  and  lower  portions  of  the  kidney  and  its 
pelvis  are  exposed  to  sight  and  touch.  At  the  outer 
border  of  the  quadratus  muscle  the  last  dorsal,  the  ilio- 
hypogastric, and  ilio-inguinal  nerves  will  be  encountered, 
and  one  or  all  may  be  divided  if  they  cannot  be  suffi- 
ciently retracted. 

Some  additional  space  can  be  gained  by  drawing  the  last 


468  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

rib  forcibly  upward  with  a  blunt  hook,  which  is  safer  than 
resection  of  a  portion  of  the  twelfth  and  even  the  eleventh 
rib,  as  has  been  done  in  a  few  cases.  If  the  pleural  or 
peritoneal  cavity  is  accidentally  opened,  the  rent  should  be 
immediately  closed  with  fine  catgut  sutures  and  protected 
by  an  iodoform-gauze  packing. 

Except  in  persons  who  are  very  fat,  this  incision  gives 
ample  room  for  exploration,  nephropexy,  nephrotomy,  and 
even  for  nephrectomy  when  the  kidney  is  not  very  much 
enlarged. 

B.  The  transverse  incision  (Fig.  218,  T)  is  begun 
just  within  the  outer  margin  of  the  sacro-lumbalis,  a  little 
below  the  twelfth  rib,  and  carried  outward  parallel  to  the 
rib  for  about  four  inches.  The  muscular  and  aponeurotic 
layers  are  successively  divided  after  recognition,  until  the 
retro-peritoneal  layer  is  reached,  and  the  kidney  exposed 
by  division  of  its  fatty  capsule,  as  in  the  preceding  descrip- 
tion. Additional  space  can  be  gained  by  a  short  longi- 
tudinal cut  at  the  inner  (vertebral)  end  of  the  main  incision. 

This  incision  is  advantageous  in  nephrectomy  when  the 
kidney  is  much  enlarged,  and  whenever  it  may  be  neces- 
sary to  insert  a  hand  into  the  peritoneal  cavity. 

C.  The  combined  longitudinal  and  transverse 
incision  consists  of  the  longitudinal  incision  joined  at  any 
part  by  the  transverse. 

I).  KdNIG's  INCISION.1  (Fig.  218,  K.) — Starting  from 
the  last  rib,  the  incision  passes  vertically  downward  along 
the  oilier  border  of  the  sacro-liinibalis  and  erector  spin;e, 
curves  forward  just  above  the  highest  part  of  the  iliac  crest, 
and  passes  horizontally  toward  the  umbilicus  to  end  at  the 
outer  border  of  the  right  rectus.  The  vertical  part  of  the 
incision  is  deepened  first  and  carried  down  layer  by  layer 
until  the  peritoneum  is  reached  in  front  of  the  anterior 
layer  of  the  lumbar  fascia.  After  the  lingers  are  placed 
in  the  lower  angle  of  this  wound  to  protect  the  peritoneum 
beneath  (he  horizontal  part,  the  latter  is  deepened  through 
the  successive  muscular  layers  until  the  peritoneum  is  ex- 
[K)sed,  It  may  often  he  advisable  to  make  the  vertical 
'Centralb.  I'.  Chir.,  L886,  No.  35,  \>.  593. 


EXPOSURE  OF  THE  KIDNEY.  469 

part  of  the  incision  run  obliquely  into  the  horizontal  in  the 
form  of  a  flattened  curve.  This  incision  affords  very  free 
access  to  the  kidney  and  a  good  part  of  the  ureter,  and  the 
size  of  the  wound  docs  not  materially  add  to  the  risks, 
hut  rather  lessens  them  by  the  increased  facility  afforded 
for  dealing  with  the  pedicle  or  any  complications. 

At  the  close  of  the  operation  the  divided  muscles  in  the 
horizontal  and  curved  parts  of  the  incision  arc  united  by 
deep  sutures  and  heal  readily,  while  the  vertical  part  can 
hi'  packed  and  drained  if  necessary.  In  any  ordinary  case 
the  horizontal  part  of  this  incision  need  not  he  extended 
beyond  the  vertical  prolongation  of  the  anterior  axillary 
line. 

Nephrotomy. — The  kidney  is  exposed  by  the  longitudinal 
lumbar  incision,  and  if  the  abscess  or  cyst  which  has  made 
the  operation  necessary  is  perfectly  apparent  it  only  re- 
mains to  cut  into  the  most  prominent  part  of  the  diseased 
tissue  with  the  knife  or  thermo-cautery.  But  if  there  is 
any  doubt  about  the  presence  or  location  of  the  disease  it 
must  be  sought  by  an  aspirating  needle  passed  through  the 
convex  border  of  the  kidney  and  its  track  followed  by  a 
knife.  A  finger  then  plugs  and  enlarges  this  incision 
while,  if  necessary,  an  assistant  makes  counter-pressure 
through  the  anterior  abdominal  wall  to  lift  the  kidney  into 
the  incision  ;  then  if  the  cavity  is  very  irregular,  or  if 
there  are  separate  pouches,  the  septa  should  be  freely 
broken  down  to  secure  efficient  drainage,  and  the  interior 
of  the  cavity  thoroughly  scraped  with  a  sharp  spoon  if  its 
condition  requires  it. 

Occasionally  it  Mill  be  possible  and  desirable  to  draw 
the  edges  of  the  sac  into  the  parietal  wound  and  stitch 
them  to  the  skin  or  deeper  tissues.  Rubber  tubes  packed 
around  with  iodoform  gauze  are  passed  into  all  parts  of  the 
abscess  cavity  for  drainage,  and  into  any  spaces  in  the 
cellular  tissue  about  the  kidney  which  may  have  been 
opened  up  and  infected. 

The  extremities  of  the  external  wound  are  drawn  to- 
gether with  silk,  and  a   large  absorbent  dressing  applied, 

Nephrolithotomy. — After  the  kidney  has  been  exposed. 


470  ABDOMINAL  WALL,  STOMACH,  AND  INTESTINES. 

preferably  by  Konig's  incision,  which  also  gives  access  to 
the  upper  part  of  the  ureter,  the  surgeon  proceeds  to  seek 
for  signs  of  the  presence  and  location  of  a  calculus ;  the 
horizontal  part  of  this  incision  should  not  be  made  at  first 
of  the  full  length,  but  later  it  is  prolonged  if  found 
necessary. 

The  posterior  surface  of  the  gland  is  freed  and  the  kid- 
ney palpated  between  the  thumb  and  finger  and  any  click 
or  spot  of  especial  density  noted. 

A  fine  needle  is  then  passed  systematically  through  the 
cortex  or  wall  of  the  pelvis  at  intervals  of  half  au  inch, 
and  not  deeper  than  two  and  a-half  inches  in  a  normal 
adult  kidney,  in  order  to  avoid  possible  injury  to  the 
main  vessels.  Should  this  fail  to  detect  the  stone,  the 
finger  may  be  introduced  through  an  incision  in  the  cor- 
tex and  thus  a  thorough  digital  examination  be  made  of 
the  interior  of  the  pelvis  and  calices. 

If  no  stone  is  found  the  wound  is  closed  with  catgut 
sutures  passed  through  the  substance  of  the  kidney,  and 
the  external  wound  is  brought  together  around  a  drainage 
tube  placed  in  contact  with  the  renal  wound. 

AVhen  a  stone  is  felt  by  the  needle,  an  incision  is  made 
with  the  knife  or  thermo-cautcry  through  the  cortex  lon- 
gitudinally. Unless  it  is  very  manifestly  better  to  open 
the  pelvis  directly,  an  incision  through  the  cortex  is  pre- 
ferable to  one  through  the  walls  of  the  pelvis  on  account 
of  the  less  danger  of  a  urinary  fistula  and  troublesome 
hemorrhage.  Bleeding  from  the  parenchyma  is  readily 
controlled  at  the  last  by  deep  sutures  closing  the  wound 
in  the  kidney. 

Through  the  opening  thus  made  the  stone  is  picked  or 
scooped  out.  If  it  is  large  or  branched  it  may  have  to  be 
crushed  with  a  lithotrite  or  strong  sequestrum  forceps; 
septa  should  be  divided  with  blunt-pointed  scissors  J  oc- 
casionally  stones  have  been  encountered  so  large,  or  so 
numerous  and  diflicull  of  removal,  that  nephrectomy  has 
been  considered  wiser  than  nephrolithotomy.  After  re- 
moval of  the  stone  Hie  orifice  of  the  ureter  is  sought  and 
thai   canal  explored   to  determine  whether   it   is  free  or 


KIDNEY.  171 

whether  plugged  by  a  stone  or  mass  of  fibrin.  If  such 
an  obstruction  is  found  it   may  be  pushed   back   into  the 

kidney,  or  washed  out  by  a  stream  of  water  directed  into 
the  distended  ureter  through  the  renal  wound,  or  perhaps 
poshed  downward  into  the  bladder. 

The  stone  or  stones  having  been  extracted  from  the 
kidney,  the  wound  in  its  substance  or  in  the  pelvic  wall  is 
closed  with  catgut  sutures  unless  there  is  so  much  suppu- 
ration present  that  every  facility  must  be  given  for  the 
escape  of  pus.  Sometimes  the  gland  will  have  become  a 
mere  abscess  cavity  containing  the  stone.  Rubber  tubes 
and  iodoform-gauze  packing  are  placed  in  contact  with  the 
kidney  wound  or  in  its  interior,  as  its  condition  may  re- 
quire, and  in  the  space  possibly  opened  up  behind  it.  A 
strip  of  gauze  is  carried  down  to  the  peritoneum  beneath 
the  curved  part  of  the  external  wound,  if  Konig's  incision 
has  been  used,  and  the  wound  closed  with  silk  sutures  up 
to  the  space  where  the  drainage  emerges. 

Lumbar  Nephrectomy.  —  The  kidney  is  exposed  by 
Konig's  incision,  but,  if  there  is  any  doubt  about  its  re- 
moval, it  should  first  be  explored  by  the  longitudinal 
incision,  and  afterward  a  transverse  incision  of  the  neces- 
sary length  can  be  added  at  any  convenient  part  of  the 
longitudinal.  The  length  of  the  transverse  or  horizontal 
part  of  Konig's  incision  is  regulated  by  the  size  of  the 
tumor.  If  inflammation  has  not  materially  changed  the 
tissues  immediately  surrounding  the  kidney,  it  is  compara- 
tively easy,  after  reaching  its  posterior  surface,  and  tearing 
through  the  perirenal  fat,  to  work  the  fingers  in  close 
contact  with  the  capsule  around  the  convex  border  and 
the  two  extremities  and  enucleate  the  kidney  from  its  bed 
by  separating  all  the  attachments  except  the  pedicle  con- 
stituted by  the  renal  vessels  and  the  ureter. 

In  cases  of  long-continued  suppuration  where  every- 
thing has  become  matted  together,  as,  for  instance,  after 
nephrotomy  for  abscess,  it  may  be  easier  to  open  the  cap- 
sule and  separate  the  kidney  from  its  interior.  The 
manipulations  must  be  gentle  and  without  undue  traction 
on  the  pedicle,  and  if  abnormal  vessels  are  encountered 


472  ABDOMINAL    WALL,  STo.MAcJL   AND  /.V 7 V:\77. VAX 

at  the  extremities  of  the  gland  they  should  he  divided 
between  double  catgut  ligatures.  After  isolation  of  the 
pedicle  it  may  be  tied  off  in  sections  by  silk  ligatures 
passed  on  a  large  full  curved  aneurism  pedicle  needle  ; 
occasionally  the  main  artery  can  be  recognized  by  sight  or 
touch,  and  it  is  desirable  that  it,  as  well  as  the  ureter, 
should  receive  a  separate  ligature  whenever  possible.  If 
the  pedicle  cannot  be  isolated  and  brought  into  view  or 
reached  on  account  of  the  condition  or  situation  of  the 
adhesions,  the  entire  pedicle  can  be  tied  &n  masse,  pref- 
erably by  the  elastic  ligature,  which  is  drawn  tight  by  the 
lingers  in  the  depths  of  the  wound  and  retained  by  a  knot 
or  clamp. 

The  part  of  the  kidney  substance  distal  to  the  ligature 
is  then  cut  away,  leaving  enough  margin  to  prevent  slip- 
ping of  the  ligature,  and  the  large  stump  which  some- 
times remains  when  the  adhesions  to  the  anterior  surface 
have  been  very  extensive  is  scraped  as  much  as  is  safe 
and  the  elastic  ligature  is  left  to  slough  out.  Occasion- 
ally the  pedicle  may  be  secured  by  a  long,  strong  clamp 
till  the  kidney  is  excised  and  then  the  pedicle  is  tied  by 
one  or  more  ligatures  on  the  proximal  side  of  the  clamp. 
If  the  ureter  has  been  separately  divided  it  is  well  to  close 
it  with  a  ligature,  and  if  necessary  to  disinfect  the  stump 
or  fix  it  in  the  external  wound.  The  pedicle  is  finally 
again  inspected  to  avoid  any  chance  of  hemorrhage,  and 
then  after  the  insertion  of  rubber  drainage  tubes  and  iodo- 
form-gauze  packing  the  external  wound  is  partially  closed. 

During  the  course  of  a  nephrectomy  it  may  be  necessary 
to  enter  the  abdominal  cavity  ;  this  can  be  done  through 
the  anterior  extremity  of  Konig's  or  of  the  transverse  in- 
cision ;  the  surrounding  peritoneal  cavity  is  protected  by 
the  usual  sponge-packingj  ami  after  removal  of  the  latter 
:ii  the  close  of  the  operation  an  iodoform-gauze  packing  is 
inserted    unless   there    is   a   certainty   of  asepsis,  in  which 

case  the  peritoneum  can  be  again  closed  tight. 

Abdominal  Nephrectomy. — The  place  of  selection  for  the 
parietal  incision  is  al  the  outer  border  of  the  rectus  muscle, 
where  it   i-  sometimes  called   Langenbuch's  incision.     It 


KIDNEY.  473 

should  not  be  less  than  four  inches  long,  and  should  have 
its  center  as  nearly  as  possible  opposite  the  center  of  the 
tumor.  The  incision  is  sometimes  made  parallel  to  this, 
but  further  outward  with  the  idea  of  making  the  operation 
wholly  extra-peritoneal,  and  then  it  is  only  a  modification 
of  lumbar  nephrectomy  by  the  Longitudinal  incision. 
Sometimes  the  abdomen  is  opened  in  the  median  line. 
After  division  of  the  tissues  in  successive  layers,  including 
the  peritoneum,  the  visceraare  pushed  aside  and  protected 
by  Hat  sponges  or  brought  out  of  the  abdomen  and  wrapped 
in  warm  cloths. 

The  peritoneum  over  nearly  the  whole  length  of  the  en- 
larged kidney  is  then  incised  longitudinally  on  the  outer 
side  of  the  colon  in  order  not  to  interfere  with  the  blood- 
supply  of  the  latter.  This  must  always  be  done  in  this 
way  unless  the  size  of  the  tumor  and  the  position  of  the 
colon  make  it  impracticable.  Occasionally  it  is  possible, 
as  shown  by  Halsted,  to  attach  the  edges  of  the  divided 
peritoneum  covering  the  kidney  to  those  of  the  divided 
anterior  parietal  peritoneum,  and  thus  entirely  to  shut  off 
the  general  peritoneal  cavity  from  the  field  of  operation. 
By  working  with  the  fingers  or  blunt-pointed  scissors  the 
peritoneum  is  stripped  from  the  anterior  surface  of  the 
gland  and  the  structures  at  the  hilum  exposed.  All  ves- 
sels, as  they  are  encountered,  are  secured  in  advance 
whenever  possible  and  divided  between  double  ligatures. 
It  may  even  be  advantageous  to  go  directly  to  the  artery 
through  a  special  incision  in  the  peritoneum  and  tic  it  as 
the  first  step  in  the  operation.  The  ureter  is  then  isolated 
between  two  ligatures,  and  if  extensively  diseased  it  is 
brought  out  of  the  abdomen  behind  and  fastened  to  the 
skin  through  the  wound  made  in  the  loin  for  drainage  ;  or 
if  healthy  the  stump  is  simply  disinfected  and  left. 

During  the  removal  of  the  kidney  every  effort  must  be 
made  to  avoid  infection  of  the  peritoneal  cavity  by  its 
contents  or  those  of  the  ureter.  After  this  the  gap  in  the 
posterior  parietal  peritoneum  may  be  rapidly  closed  with 
a  continuous  catgut  suture,  and  lumbar  drainage  provided 
for  the  space  formerly  occupied  by  the  kidney  by  the  in- 
sertion of  a  rubber  tube  and  gauze,  if  necessary,  through 


474  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

■a  small  incision  made  in  the  loin.  The  abdominal  wound 
is  closed  in  the  usual  way,  with  or  without  drainage,  ac- 
cording to  the  necessities  of  the  case. 

The  presence  and  condition  of  the  other,  presumably 
sound,  kidney  should  always  be  ascertained  as  soon  as  the 
peritoneal  cavity  is  opened  in  abdominal  nephrectomy. 

In  cases  of  floating  kidney  in  which  the  gland  is  fully 
pedunculated  and  invested  by  peritoneum,  its  removal 
will  be  conducted  as  in  the  case  of  any  other  pedunculated 
abdominal  tumor,  without  stripping  off  the  peritoneum. 

Nephrorrhaphy  or  Nephropexy. — This  is  the  operation  by 
which  an  abnormally  movable  kidney  is  permanently  fixed 
in  its  proper  position  by  suturing  it  to  the  abdominal  wall. 

The  kidney  is  exposed  by  the  longitudinal  lumbar  in- 
cision at  the  outer  border  of  the  sacro-lumbalis,  and  the 
fatty  capsule  divided  longitudinally  and  stripped  back 
from  the  surface  of  the  kidney.  Three  or  four  stout  catgut 
or  silkworm-gut  sutures  are  then  passed  with  a  curved 
needle  from  the  anterior  to  the  posterior  surface,  well 
within  the  convex  border,  at  intervals  of  about  half  an 
inch,  and  then  through  the  cut  edge  of  the  lumbar  fascia 
in  the  inner  lip  of  the  wound,  so  that  when  tied  they  hold 
the  kidney  snugly  up  against  the  abdominal  wall.  The 
wound  may  then  be  closed  for  primary  union,  or  packed 
with  iodoform  gauze  to  heal  by  granulation.  Guyon  sought 
to  strengthen  the  cicatricial  connection  by  removing  a  long 
strip  of  the  fibrous  capsule  ;  and  Sulzer  '  recommends  that 
the  capsule  be  split  and  reflected  so  as  to  form  a  flap  which 
can  be  stitched  in  the  parietal  wound.  Others  have  sought 
to  avoid  sutures  and  increase  the  extent  and  strength  of 
tin'  adhesion  by  holding  the  kidney  up  against  the  sides 
of  the  wound  by  means  of  a  gauze  loop  passed  around  its 
lower  portion  and  left  in  place  for  a  week  or  more. 

URETER. 

Anatomy.- — The   ureter  lies  behind  the  peritoneum   on 

the  psoas  muscle  and  genito-crural  nerve  in  the  upper  part 

1  I'.ut.  Zeit  r.  Chir.,  Vol.  XXXI. 

2('itl)iii  :  American  Journal  of  the  Medical  Sciences,  L892,  Vol.  (III.. 
p.  43. 


URETKR.  475 

of  its  course,  and  is  crossed  from  within   outward  by  the 
spermatic  or  ovarian  vessels.     As  the  ureters  approach  the 
pelvis  they  lie  close  to  the  spine  between  the  psoas  and  the 
bodv  of  the  vertebra,  the  right  ureter  being  a  little  further 
outward  than  the  left,  owing  to  the  interposition  of  the 
inferior  vena  cava,  with  which  it  is  in  close  relationship. 
When  the  peritoneum  in  this  region  is  stripped  up  from 
the  parts  beneath  the  ureter  will  always  be  found  adher- 
ing to  its  under  surface  and  on  the  left  side,  about  half  an 
inch  to  an  inch  outside  of  the  point  where  the  peritoneum 
becomes  attached  to  the  spine  ;   on  the  right  side  the  dis- 
tance is  slightly  greater.     The  ureters  cross  the  common 
or  external  iliac  vessels  to  enter  the  pelvis,  where  they  lie 
pretty  closely  over  the  lateral  edges  of  the  sacrum.    They 
then  run  in  the  recto-vesical  fold  of  peritoneum  to  enter 
the  base  of  the  bladder  at  a  distance  of  two  inches  from 
each  other  and  pass  for  a  half  to  three-quarters  of  an  inch 
between  the  mucous  and  muscular  coats  of  the  viscus  be- 
fore terminating.      The  vas  deferens  is  between  the  ureter 
and  the  bladder.     The  narrowest  part  of  the  canal  is  close 
to  the  bladder,  and  this  region,  which  is  the  most  difficult 
of  access,  is  also  the  one  where  a  calculus  is  most  likely 
to  lodge.     In  the  female  the  ureter  for  the  last  two,  and 
in  some  cases  three,  inches  of  its  course,  lies  in  the  broad 
ligament  in  close  relationship  with  the  cervix  and  vault 
of  the  vagina,  and  it  can  be  reached  by  an  incision  in  the 
vault  extending  outward  and  backward  within  the  layers 
of  the  broad  ligament. 

Operations  on  the  Ureter.' — Almost  the  only  indications 
for  operations  upon  the  ureter  are  found  in  wounds  of  it 
or  in  the  necessity  for  the  removal  of  an  impacted  cal- 
culus. The  ureter  should  always  be  opened  extra-peri- 
toneally  for  the  removal  of  a  stone,  inasmuch  as  the 
wound  cannot  be  satisfactorily  closed  with  sutures,  and  it 
has  been  proven  that  at  least  a  longitudinal  wound  will  in 
time,  if  there  is  proper  drainage,  spontaneously  close  and 
allow  the  urine  to  pass  in  its  natural  channel. 

•A  summary  of  this  subject  with  the  bibliography  will  be  found  in 
the  Annals  of  Surgery,  1894,  p.  257. 


47ti  ABDOMINAL   WALL.  STOMACH,  AND  INTESTINES. 

The  ureter  should  generally  first  be  explored  through  :i 
median  abdominal  opening  made  below  the  umbilicus, 
and  always  thusexplored  if  there  is  doubt  about  the  loca- 
tion of  the  stone.  In  some  instances  it  has  thus  been 
possible  to  manipulate  the  calculus  up  into  the  pelvis  of 
the  kidney  or  down  into  the  bladder,  and  even  when  it 
was  soft  to  break  the  stone  into  fragments  with  the  fingers 
and  then  get  them  into  the  bladder. 

[f  the  ureter  must  he  opened,  an  incision  is  made  three 
or  tbnr  inches  long  wherever  necessary  in  a  line  drawn 
from  a  point  on  the  anterior  edge  of  the  sacro-lumbalis  a 
finger's  breadth  below  the  twelfth  rib,  parallel  to  the  rib 
as  far  as  its  tip,  thence  downward  toward  the  middle  of 
Poupart's  ligament  till  about  opposite  the  anterior  superior 
spine  of  the  ilium.  From  this  point  the  line  again  turns 
inward  to  end  at  the  outer  border  of  the  rectus  muscle. 

The  tissues  arc  divided  layer  by  layer  till  the  perito- 
neum is  reached,  and  then  the  latter  membrane  is  gently 
raised  by  the  fingers  from  the  parts  beneath  till  the  ureter 
i-;  exposed  adhering  to.  its  under  surface.  In  the  middle 
third  of  the  course  of  the  ureter  it  will  be  found  about  half 
an  inch  to  an  inch  from  the  spinal  attachment  of  the  peri- 
toneum.  The  ureter  is  incised  longitudinally  over  the 
stone  sufficiently  to  extract  the  latter.  In  several  in- 
stances this  wound  has  then  been  closed  by  a  continuous 
suture  of  fine  silk  through  the  outer  wall  of  the  ureter, 
but  not  penetrating  its  lumen,  and  with  one  end  of  the 
suture  left  within  reach  from  the  parietal  opening  to  re- 
move it  in  case  of  suppuration.  This  may  at  any  rate 
narrow  the  opening  and  so  hasten  its  repair,  though  ( 'abot  ' 
considers  suturing  a  wound  of  the  ureter  unnecessary. 

A  rubber  tube  and  iodoform -gauze  packing  is  placed  in 
contact  with  the  ureteral  wound  for  drainage  of  escaping 
urine,  ami  the  ends  brought  out  of  the  external  incision 
which  is  partially  closed  around  them. 

In  some  cases  where  the  -tone  can  be  felt  through  the 
vault  of  the  vagina,  and  it  i-  between  the  layers  of  the 
broad    ligament    not    more  than  an  inch  or  an    inch  and  a- 

1  Loc.  <i(- 


URETER  477 

lialf  from  the  bladder,  an  incision  can  be  made  in  the 
vault  outward  and  backward  and   the  anger  pushed   up 

separating  the  intervening  tissues  in  the  broad  ligament 
till  the  stone  is  reached.  The  ureter  is  then  opened  longi- 
tudinally on  its  nnder  side  and  the  stone  picked  out.  Such 
a  wound  has  been  successfully  closed  with  sutures,  but  it 
will  generally  be  found  sufficient  to  place  a  drainage  tube 
and  packing  in  contact  with  it  ami  bring  the  ends  out 
through  the  vagina.1 

In  other  cases  if  the  stone  has  reached  the  bladder 
cavity  and  lies  between  the  mucous  and  muscular  coats, 
it  should  be  attacked  through  the  interior  of  the  bladder, 
probably  by  a  suprapubic  cystotomy  ;  but,  if  it  is  further 
off  and  the  bladder  wall  must  be  opened  to  expose  the 
stone,  there  is  great  danger  of  urinary  infiltration  in  the 
surrounding  parts,  and  Cabot's  method,  described  below, 
should  be  used. 

With  these  exceptions  the  lower  third  of  the  ureter 
must  generally  be  approached  from  behind.  An  incision 
is  made  three  or  four  inches  long,  starting  just  below  the 
tip  of  the  coccyx  and  following  the  lateral  border  of  that 
bone  and  the  sacrum  on  the  side  of  the  affected  ureter. 
The  sacro-sciatic  ligaments  are  divided  close  to  the  sacrum 
and  the  coccyx  excised,  and  if  necessary  the  lower  lateral 
border  of  the  sacrum  also,  as  in  Kraske's  operation. 

With  a  large  sound  in  the  rectum  to  map  it  out  and 
push  it  aside,  the  ureter  is  sought  for  close  to  the  edge  of 
the  sacrum  and  opened  longitudinally  on  its  under  side 
opposite  the  calculus  sufficiently  to  extract  the  latter. 
The  resulting  wound  is  simply  packed  and  drained. 

Wounds  of  the  Ureter. — Extraperitoneal  wounds  of  the 
ureter  involving  a  part  of  its  circumference  should  be 
treated  as  already  described,  i.  e.,  by  a  counter-opening 
and  drainage  through  the  abdominal  wall  in  a  direction  as 
nearly  as  possible  directly  backward.  When  the  wound 
has  been  intraperitoneal  or  has  involved  the  entire  cir- 
cumference of  the  ureter,  the  divided  ends  have  been  li- 
gated  with  catgut  and  the  stumps  disinfected  and  covered 
1  ( Jabot  :  Loc.  cit. 


4  7S  ABDOMINAL   WALL,  STOMACH,  AND  INTESTINES. 

with  an  iodoform-gauze  packing,  which  was  brought  out 
of  the  abdomen,  and  the  corresponding  kidney  has  then 
been  extirpated. 

Or,  after  ligating  and  disinfecting  the  divided  lower 
end  of  the  ureter,  the  upper  end  has  been  brought  out  in 
the  loin  through  a  counter-opening  made  above  the  crest 
of  the  ilium  behind,  and  a  urinary  fistula  established,  for 
the  cure  of  which  nephrectomy  has  been  subsequently 
performed. 

Some  recent  experiments  on  dogs1  seem  to  prove  that 
one  ureter  can  be  implanted  in  the  rectum,  or  colon,  with- 
out especial  danger  or  subsequent  inconvenience,  and  this 
fact  might  be  of  great  service  in  case  of  an  accidental 
division  of  one  ureter  during  a  pelvic  operation. 

There  is  also  reason  to  believe  that  it  may  be  possible 
to  obtain  reunion  of  the  divided  ureter  and  reestablish- 
ment  of  the  flow  of  urine  to  the  bladder  by  partial  sutur- 
ing of  the  divided  ends  after  trimming  them  obliquely  or 
into  corresponding  salient  and  reentrant  V's.  If  union 
can  be  thus  obtained  over  a  part  of  the  wall,  the  re- 
maining fistula  may  heal  as  after  longitudinal  or  oblique 
wounds.  A  few  cases  have  been  reported  in  which  in- 
vagination of  the  upper  into  the  lower  end  has  been  suc- 
cessful.2 

In  several  reported  instances,  when  it  has  been  divided 
near  its  lower  end,  the  ureter  has  been  implanted  in  the 
bladder  above  the  point  where  it  normally  enters  this  vis- 
cus.  The  cut  end  of  the  ureter  is  slit  up  longitudinally 
for  half  an  inch  and  its  margins  sutured  witli  catgut  to 
the  edges  of  an  opening  in  the  bladder.  Drainage  must 
lie  provided  for. 

Kelly1  has  successfully  employed  on  the  human  sub- 
jeci  a  method  used  by  Van  Hook  in  experiments  on  dogs, 
and  has  called  the  operation  wretero-ureterostomy.  Other 
similar  eases  are  being  reported.  The  divided  extremity 
of  the  distal  segment  is  tied  off  by  ligature  and  just  below 

>  Annals  Surgery,  L892,  Vol.  XVI.,  ]».  193. 
'Markoeand  Wood,  Annals  of  Surgery,  June,  1899. 
'Annals Surgery,  1894,  |>.  7<». 


URETER.  479 

the  latter  the  lumen  of  the  distal  segment  is  opened  longi- 
tudinally sufficiently  to  permit  the  upper  segment  to  be 
inserted  into  the  lower.  A  couple  of  sutures  in  the  cut 
edge  of  the  proximal  stump  are  threaded  on  needles  and 
passed  through  the  slit  into  the  lumen  of  the  lower  stump 
and  out  through  its  walls  just  below  the  longitudinal 
opening  and  used  to  draw  the  upper  into  the  lower  por- 
tion of  the  tube.  The  ends  of  these  sutures  are  tied,  and 
one  or  two  others  inserted  at  the  point  where  the  stumps 
are  in  contact.  Gauze  is  then  packed  around  the  suture 
line  and  brought  out  of  the  abdominal  wound  for  drainage. 


CHAPTER    VII. 

OPEKATIOXS   UPON   THE    GENITO-URINARY   OR- 
GANS  OF   THE   MALE. 

CASTRATION. 

The  usual  preparations  for  an  antiseptic  operation  are 
made,  and  a  sterilized  towel  wet  in  a  1:1000  solution  of 
bichloride  of  mercury  is  wrapped  around  the  penis  and 
pinned  to  the  loose  skin  at  its  root.  The  scrotum  on  the 
affected  side  is  grasped  by  the  thumb  and  fingers  of  the 
left  hand  and  drawn  tight  in  such  a  way  as  to  make  the 
diseased  testis  and  its  cord  prominent  and  tense.  An  in- 
cision is  then  made  from  the  external  abdominal  ring 
along  the  entire  length  of  the  anterior  portion  of  the 
scrotum;  but  if  the  skin  is  involved  this  incision  should 
be  made  elliptical  in  the  direction  required  to  include  the 
diseased  area. 

After  division  of  the  skin  and  dartos  the  testicle  is 
slipped  out  of  the  wound,  and  the  cord  is  dissected  out 
until  a  healthy  portion  is  reached  ;  it  may  be  necessary 
to  follow  it  into  the  inguinal  canal,  splitting  the  apon- 
eurosis of  the  external  oblique  for  the  purpose.  It  is  then 
divided  by  repeated  cuts  of  the  knife  and  the  vessels  are 
caught  and  tied  with  catgut  as  they  bleed.  Hemorrhage 
from  the  scrotal  wound  must  be  completely  checked  by 
ligation  or  by  torsion  and  pressure. 

Drainage  is  unnecessary  unless  the  wound  lias  been  ex- 
posed to  infection,  in  which  ease  a  small  rubber  tube  with 
lateral  perforations  is  placed  in  its  depths  and  brought 
out  at  the  mosl  dependent  angle,  while  the  surface  is 
partly  drawn  together  around  an  iodofbrm-gau/e  packing. 
Sometimes  :i  healthy  part  of  the   cord   cannot    be    reached 

:uid  ii  musl  be  li.-d  through  diseased  tissue.     It  is  then 

180 


HYDROCELE.  481 

especially  necessary  to  ligate  each  vessel  separately,  and 
an  iodoform-gauze  packing  is  placed  in  contact  with  the 
stump. 

A  drv  dressing  is  applied  with  a  hernia  bandage,  over 
which  is  placed  a  sheet  of  rubber  tissue,  perforated  for  the 
penis,  to  prevent  soiling  by  urine,  and  the  whole  retained 
by  a  flannel  spica  bandage. 

HYDROCELE. 

The  operations  for  the  relief  of  hydrocele  are  palliative 
or  radical.  The  object  of  the  former  is  simply  to  remove 
the  liquid  from  the  sac;  that  of  the  latter  to  prevent  its 
reaccumulation  by  excising  the  sac,  or  by  obliterating  its 
cavity  by  exciting  adhesive  inflammation  of  its  walls. 
Injection  of  the  tincture  of  iodine  is  the  means  most  com- 
monly employed  for  the  latter  purpose.  The  position  of 
the  testicle  within  the  sac  should  always  be  ascertained,  in 
order  that  it  may  not  be  injured  by  the  trocar.  This  is 
best  accomplished  in  most  cases  by  examining  the  sac  by 
transmitted  light,  the  testicle  appearing  as  an  opaque  spot 
in  the  general  translucency  ;  its  usual  position  is  at  the 
lower  posterior  portion  of  the  sac. 

Puncture  of  the  Sac. — The  tumor  is  grasped  at  its  up- 
per portion  in  such  a  manner  as  thoroughly  to  stretch  the 
shin  covering  it,  and  a  sterilized  trocar  is  plunged  into 
the  center  of  its  anterior  surface,  supposing  the  testicle  to 
occupy  its  usual  position  below  and  behind.  The  depth 
to  which  the  trocar  enters  is  regulated  by  the  finger 
placed  along  its  side,  and  the  surgeon  satisfies  himself 
that  the  point  is  well  within  the  sac  by  moving  it  freely 
in  all  directions.  The  cannla  should  fit  the  trocar  snugly 
in  order  that  its  anterior  end  may  not  push  the  tissues  be- 
fore it  instead  of  penetrating  them.  If  the  intention  is 
only  to  remove  the  liquid,  the  cannla  is  withdrawn  as 
soon  as  the  flow  has  ceased,  and  the  puncture  closed  with 
adhesive  plaster  or  collodion  ;  but  if  a  radical  cure  is  to  be 
attempted,  the  tincture  of  iodine  must  first  be  thrown  in. 

(are  must  be  taken  that  the  injection  is  not  thrown 
into  the  subcutaneous  connective  tissue,  an  accident  that 


482       GENITO-URINABY  ORGANS  OF  THE  MALE. 

is  very  likely  to  be  followed  bv  slouching  of  the  scrotum  ; 
the  surest  way  of  avoiding  this  accident  is  to  throw  in 
the  injection  before  the  liquid  has  entirely  ceased  to  flow 
out.  If  the  accident  does  occur,  free  incisions  must  be 
made  at  once  into  the  scrotum  at  the  seat  of  the  infiltra- 
tion. 

Radical  Cure  by  Excision.  (Volkmann.) — With  every 
antiseptic  precaution  the  sac  is  freely  laid  open  by  a  longi- 
tudinal anterior  incision  and  the  cut  edges  of  the  skin  and 
tunica  vaginalis  stitched  together  all  around.  The  cavity 
is  then  lightly  packed  and  allowed  to  heal  by  granulation, 
a  process  which  requires  a  couple  of  weeks.  If  the  sur- 
geon is  sure  of  the  asepsis  the  packing  may  be  withdrawn 
at  the  end  of  three  days,  and  then  by  applying  firm  pres- 
sure, the  wound  can  be  caused  to  heal  much  sooner. 

VARICOCELE. 

The  treatment  of  varicocele  may  be  palliative  or  radi- 
cal. By  the  former,  support  is  given  to  the  testicle  and 
the  over-distended  veins ;  by  the  latter,  it  is  sought  to 
obliterate  the  lumen  of  the  veins  at  one  or  more  points. 
There  are  several  risks  involved  in  the  radical  treatment, 
which,  when  taken  in  connection  with  the  usual  harmless- 
ness  of  the  affection  and  the  efficacy  of  palliative  measures, 
should  make  the  surgeon  slow  to  employ  it.  The  risks 
are  :  Possible  sepsis,  possible  atrophy  of  the  testicle,  in 
consequence  of  the  obliteration  of  all  the  veins  or  the  in- 
clusion of  the  artery  in  the  ligature  ;  and,  finally,  the  re- 
turn of  the  affection  if  all  the  veins  are  not  obliterated. 
The  palliative  treatment  consists  in  wearing  a  suspensory 
bandage,  or  in  excising  a  large  portion  of  the  scrotum, 
with  the  expectation  that  what  is  left  will  act  as  a  natural 
suspensory. 

Excision  of  the  Scrotum. — A  long  clamp  is  required, 
between  the  blades  of  which  a  large  fold  of  the  Scrotum  is 
pinched  up  parallel  to  and  including  the  raphe.  This  fold 
i-  i  In  n  cut  off  about  one-eighth  of  an  inch  from  the  outer 
Bide  "I*  the  blades,  and  numerous  interrupted  sutures  ap- 
plied before  the  clamp  is  removed.     If  bleeding  i-  feared, 


VARICOCELE.  483 

these  sutures  should  be  cut  about  a  foot  long,  and  not  tied 
until  after  the  clamp  has  been  taken  off  and  all  bleeding 
points  secured. 

The  radical  treatment  consists  in  obliterating  the  lumen 
of  the  veins  by  dividing  them,  excising  a  portion,  com- 
pressing and  strangulating  them  by  means  of  ligatures  or 
clamps,  or  simply  exposing  them  to  the  air.  Of  these  ex- 
cision is  the  only  method  to  be  commended. 

Subcutaneous  Ligature. — A  needle  carrying  a  catgut  or 
aseptic  silk  ligature  is  passed  through  between  the  veins 
and  the  cord,  reentered  at  the  point  of  emergence,  passed 
around  the  other  side  of  the  veins  close  under  the  skin 
and  brought  out  and  tightly  tied  at  the  first  point  of 
entry.  If  this  is  very  exactly  done,  so  as  not  to  include 
the  deeper  part  of  the  skin  at  either  puncture  in  the  loop, 
and  is  treated  antiseptically,  it  will  usually  heal  without 
suppuration.  Its  execution  is  facilitated  by  making  the 
punctures  with  a  knife. 

Open  Method  of  Ligation. — A  fold  of  the  scrotum  over 
the  enlarged  veins  above  the  globus  major  is  pinched  up 
and  divided  with  scissors,  making  a  longitudinal  incision 
about  an  inch  long.  The  thumb  and  forefinger  of  the  left 
hand  grasp  the  vas  deferens,  pushing  it  backward,  while 
the  veins  at  the  same  time  are  forced  forward  into  the 
cutaneous  wound.  The  veins  are  isolated  by  a  slight 
dissection  with  the  knife  or  blunt-pointed  scissors  and  a 
ligature  of  catgut  or  fine  silk  is  passed  under  them  by  an 
aneurism  needle.  After  another  inspection  to  make  cer- 
tain the  vas  is  not  included,  the  ligature  is  tied  tightly 
and  the  ends  cut  short.  The  small  incision  is  then  closed 
without  drainage  and  closed  antiseptically. 

Some  surgeons  pass  the  ligature  double,  tying  off  a 
segment  of  the  vein,  which  is  then  excised  and  the  divided 
ends  brought  into  apposition  by  the  long  ends  of  the  lig- 
ature, which  are  then  cut  short. 

Others  thoroughly  expose  a  single  vein,  divide  it,  and 
then  dissect  out  and  excise  an  inch  or  two  of  it ;  this  is 
repeated  with  one  or  several  others  according  to  circum- 
stances, 


4S4      GENITO-URINABT  ORGANS  OF  THE  MALE. 

AMPUTATION   OF   THE   PENIS. 

Partial. — The  root  of  the  penis  is  constricted  by  a  piece 
of  rubber  tubing  and  the  skin  is  slightly  drawn  back  to- 
ward the  pubes  and  divided  by  a  circular  sweep  of  the 
knife.  With  a  sound  in  the  urethra  the  corpora  caver- 
nosa are  cut  transversely  at  the  level  of  the  retracted  skin 
down  to  the  corpus  spongiosum,  which  is  then  dissected 
out  by  a  few  strokes  of  the  knife,  and,  after  withdrawal 
of  the  sound,  is  cut  transversely,  including  the  urethra, 
about  half  an  inch  longer  than  the  corpora  cavernosa  to 
allow  for  retraction  of  the  urethra.  The  cut  ends  of  the 
vessels  in  sight,  including  the  two  dorsal  arteries  and  the 
arteries  of  the  eorpora  cavernosa,  which  lie  in  the  center 
of  these  bodies,  are  tied  with  fine  catgut,  the  tourniquet 
removed,  and,  after  checking  the  hemorrhage  by  ligation 
or  torsion,  the  cut  edges  of  the  urethra  and  skin  are 
united  with  fine  silk. 

To  prevent  cicatricial  contraction  of  the  mouth  of  the 
urethra,  the  latter  should  be  split  longitudinally  for  about 
half  an  inch  on  its  under  surface  before  stitching  it  to  the 
skin. 

Complete. — The  patient  is  placed  in  the  lithotomy  posi- 
tion, a  sound  introduced  into  the  bladder,  and  the  scrotum 
is  split  from  before  backward  along  its  raphe.  The  corpus 
spongiosum  is  dissected  out  as  far  as  the  triangular  liga- 
ment, and  divided  about  an  inch  in  front  of  the  latter 
after  withdrawal  of  the  sound. 

A  circular  incision  continuous  with  the  anterior  ex- 
tremity of  the  scrotal  incision  is  next  made  through  the 
skin  around  the  root  of  the  penis  ;  the  suspensory  liga- 
ment is  divided,  and  by  dragging  on  the  penis  and  re- 
tracting the  sides  of  the  scrotal  wound,  the  corpora  caver- 
no-;!  and  their  posterior  prolongations,  the  crura,  are 
removed  from  the  rami  of  the  pubes  and  ischium  by  the 
knife  or  periosteal  elevator.  All  the  attachments  of  the 
penis  having  thus  been  severed  and  the  bleeding  points 
tied.  ;i-  they  are  encountered,  with  fine  catgut,  the  urethra 
ie  -|>lit  for  half  an  inch  on  its  floor  and  sutured  to  the 
edges  of  the  wound  well  forward  in  the  perineum,  and  the 


OPERATIONS  FOR  PHIMOSIS.  485 

remainder  of  the  wound  is  united  between  the  testicles  so 
as  to  form  a  separate  scrotum  for  each  of  them. 

When  this  extensive  operation  is  undertaken  for  cancer 
of  the  penis  the  inguinal  glands  on  both  sides  should  be 
removed  at  the  same  time,  whether  perceptibly  enlarged 
or  not. 

OPERATIONS   FOR  PHIMOSIS. 

Dorsal  Incision. — A  director  is  passed  through  the  pre- 
putial orifice  along  the  dorsum  of  the  glans  to  the  corona, 
a  curved  sharp-pointed  bistoury  guided  along  it,  the  skin 
transfixed  at  the  point  of  the  director  and  divided  straight 
down  to  the  preputial  orifice.  Nothing  more  is  absolutely 
required,  for  the  wound  left  to  itself  will  heal  promptly; 
but  it  is  well  to  round  off  the  corners  and  to  unite  the 
edges  of  the  mucous  membrane  and  skin  by  fine  sutures. 
This  is  a  very  satisfactory  operation  when  the  prepuce  is 
not  redundant,  but  if  there  is  much  excess  of  tissue  the 
foreskin  will  present  an  awkward,  lop-eared  appearance 
for  many  years,  and  in  such  cases,  therefore,  circumcision 
is  to  be  preferred. 

This  operation  is  often  required  in  cases  of  sub-preputial 
chancroid,  and  care  should  then  be  taken  to  prevent  or 
correct  infection  of  the  wound  by  the  chancroidal  virus. 

Circumcision. — A  number  of  instruments  have  been  in- 
vented and  a  great  variety  of  methods  proposed,  which  do 
not  need  to  be  repeated  here,  for  the  object  they  had  in 
view,  that  of  insuring  division  of  the  skin  and  mucous 
membrane  of  the  prepuce  at  the  same  level,  is  not  a  mat- 
ter of  much  importance,  since  any  excess  of  the  latter  can 
be  readily  removed  afterward.  There  is,  however,  one 
modification  introduced  by  Dr.  Keyes  '  which  is  of  im- 
portance, for  it  insures  the  removal  of  the  constriction 
and  protects  the  wound  from  being  harmed  by  erections 
while  healing.  This  modification  consists  in  an  addi- 
tional longitudinal  division  of  the  skin  for  about  half  an 
inch  along  the  dorsum  of  the  penis  (Fig.  '219,  AC).     The 

'Van  Buren  and  Keves  :  Genito-Urinary  Diseases,  with  Syphilis, 
New  York,  1874,  p.  11. 


481)      GENFTO-TJRINARY   OIK  I  ASS  OF  THE  MALE. 


Fig 


corners  left  by  this  incision  arc  rounded  off,  and  the  ef- 
fect is  to  increase  the  circumference  by  twice  the  length 
of  the  incision. 

Operation. — A  probe  is  first  introduced  and  swept  over 
the  surface  of  the  glans  to  break  up  any  adhesions  that 
may  exist,  and  the  edge  of  the  preputial  orifice  is  then 
caught  at  opposite  points  with  the  thumb  and  forefinger 
of  eacli  hand  and  drawn  forward,  care  being  taken  to 
make  the  tension  upon  the  less  elastic  mucous  membrane, 
and  not  only  upon  the  skin.  While  the  prepuce  is  thus 
drawn  forward,  an  assistant  clasps  a  pair  of  long  narrow- 
bladed  forceps  vertically  upon  it  just  in 
front  of  the  apex  of  the  glans,  directing 
the  blades  forward  as  well  as  downward 
(the  penis  being  horizontal)  parallel  to 
the  general  direction  of  the  corona,  and 
the  glans  should  then  be  moved  freely 
behind  them  to  make  sure  that  it  is  not 
caught  between  the  blades.  The  portion 
of  prepuce  in  front  of  the  forceps  is  then 
cut  away  with  scissors  or  a  knife  and  the 
forceps  taken  off. 

It  will  then  be  seen  that  the  glans  is 
still  covered  by  a  more  or  less  tightly 
fitting  sheath  of  mucous  membrane,  while 
the  looser  and  more  elastic  skin  retracts 
to  or  beyond  the  corona,  leaving  a  belt  of 
raw  surface  below  (Fig.  21 9). 

The  mucous  membrane  is  next  divided  with  scissors 
along  the  dorsum  back  to  the  corona  (Fig.  21i>,  BD),  and 
the  skin  divided  in  the  same  direction  along  the  dorsum 
for  a  distance  of  half  an  inch  from  its  cut  edge  (Fig.  219, 
AC).  The  corners  arc  rounded  off,  and  the  edges  of  the 
mucous  membrane  and  skin  fastened  together  with  numer- 
ous fine  sutures,  the  first  being  placed  exactly  in  the  me- 
dian line  in  front,  the  second  at  the  fraenum.     If  fine  silk 

is  used,  and  the  sutures  placed  close  to  the  edge,  they  may 

lie  left  to  cut  their  way  out  and  come  away  in  the  dressings. 

If  broad  adhesions  exist  between  the  glans  and  prepuce, 


Circumcision.  Raw 
surface  left  by  retrac- 
tion after  Brsl  incis- 
ion. 


EPISPADIAS.  487 

and  it  is  feared  that  the  raw  surfaces  left  by  their  division 
will  reunite,  all  the  mucous  membrane  may  be  removed, 
except  a  ring  about  one-eighth  of  an  inch  wide  adjoining 
the  corona;  the  skin  is  then  drawn  forward,  and  united 
to  the  narrow  ring  of  mucous  membrane  The  raw  sur- 
face on  the  glans,  having  nothing  to  adhere  to,  cicatrizes 
naturally. 

PARAPHIMOSIS. 
A  description  of  the  methods  of  reduction  by  taxis  or 
by  compression  of  the  engorged  prepuce  and  gland  does 
not  lie  within  the  proposed  scope  of  this  work,  and  the 
operation  of  division  of  the  constricting  band  hardly  needs 
to  be  described,  for  it  consists  simply  in  dividing  the  band 
from  without  inward  at  one  or  more  points,  until  the  con- 
striction is  sufficiently  relieved  to  allow  the  prepuce  to  be 
drawn  forward.  It  is  well  to  make  the  first  incision  in 
the  median  dorsal  line  so  as  to  profit  by  it  afterward,  if  an 
operation  for  phimosis  is  considered  necessary. 

DIVISION  OF  THE  FR.ENUM. 
Yerncuil '  employs  the  following  method  :  He  makes 
the  frsenum  tense,  transfixes  it  close  to  its  attachment  to 
the  glans  with  a  narrow  bistoury  or  tenotome  held  with 
its  side  parallel  to  the  surface  of  the  penis,  and  cuts  out 
backward,  making  a  triangular  flap  nearly  half  an  inch 
long,  with  its  apex  directed  backward.  The  liberated 
glans  is  drawn  forward,  the  flap  disappears,  and  the  edges 
of  the  wound,  which  assumes  the  shape  of  a  lozenge,  are 
united  by  sutures. 

EPISPADIAS. 

The  deformity  known  as  epispadias  is  characterized  by 
fissure  of  the  roof  of  the  urethra.  In  its  complete  form 
it  is  associated  with  separation  of  the  symphysis  pubis, 
and  often  with  exstrophy  of  the  bladder,  in  which  case 
its  treatment  is  subordinate  to  that  of  the  more  important 
defect  (q.  v.).  In  its  slightest  degree  it  is  confined  to  a 
fissure  occupying  the  dorsal  portion  of  the  glans  penis, 
1  Chirurgie  R^paratrice,  1887,  p.  730. 


48S     GENITO   URINARY  ORGANS  OF  THE  MALE. 

and  extending  from  the  meatus  to  the  corona  (epis- 
padias balanique).  The  existence  of  this  form  has  been 
<lctik'<l.  luit  Verneuil1  reports  two  cases,  in  neither  of 
which  did  the  malformation  cause  any  disturbance  of 
function.  In  the  more  important  varieties  the  urethra 
lies  above  the  corpora  cavernosa  instead  of  below  them, 
and  is  open  on  the  roof  from  its  anterior  extremity  nearly 
to  the  bladder  ;  the  glans  is  fairly  developed,  and  may  be 
grooved  more  or  less  deeply  along  its  dorsum,  while  the 
rest  of  the  corpus  spongiosum  is  represented  by  a  thin 
layer  of  erectile  tissue  under  the  urethra.  There  is  some- 
times partial  or  complete  incontinence  of  urine,  and  the 
operative  indication  is  to  supply  a  channel  through  which 
the  urine  can  be  conducted  without  dribbling  to  a  urinal. 

Nelaton's  Method. — The  prepuce  is  drawn  downward 
and  forward  by  means  of  a  ligature  passed  through  it, 
and  held  in  this  position  during  the  operation.  An  in- 
cision is  then  made  along  each  side  of  the  urethral  gutter 
at  the  junction  of  the  skin  and  mucous  membrane,  begin- 
ning at  the  prepuce  and  ending  at  the  abdominal  wall. 
The  external  lip  of  each  incision  is  dissected  up  for  about 
one-sixth  of  an  inch,  forming  a  flap  on  each  side  continu- 
ous with  the  skin;  the  inner  lip  of  each  incision  is  also 
slightly  loosened.  The  flaps  must  be  made  as  thick  as 
possible. 

A  third  flap  is  then  marked  out  upon  the  abdominal 
wall,  immediately  above  the  urethral  orifice  leading  to  the 
bladder,  by  two  vertical  incisions  united  at  their  upper 
ends  by  a  transverse  one  ;  it  should  be  as  broad  as,  and  a 
little  longer  than,  the  penis,  dissected  from  above  downward 
to  it-  base,  which  corresponds  to  the  interpubic  ligament, 
and  then  reversed,  its  cutaneous  surface  inward,  and  its 
aides  made  fasl  by  sutures  to  the  inner  lips  of  the  incision 
on  the  penis,  care  being  taken  to  make  the  contact  as 
broad  as  possible.  Demarquay 2  and  Dolbeau 3  preferred 
to   make  the  flap  by  prolonging  the  firsl  two  incisions  up 

1  Loc.  cit. ,  p.  7 18. 

8 Maladies  Chirurgicales  <lu  Penis,  1*77,  p.  623. 

•  Del' Epispadias,  Paris,  1861.     Planche  IV..  Fig.  I. 


EPISPADIAS. 


489 


the  abdomen,  thinking  that  the  continuity  of  the  incisions 
upon  the  abdomen  and  penis  would  increase  the  chances 

of  success  (Fig.  220,  C,  C). 

In  order  to  give  the  abdominal  flap  greater  thickness, 
and  prevent  its  retraction  during  the  process  of  cicatriza- 
tion, Nelaton  reinforced  it  by  another  taken  from  the 
scrotum.  This  scrotal  flap  is  limited  by  concentric  curved 
incisions  (Fig.  220,  F,  F),  the  upper  one  circumscribing 
the  under  half  of  the  root  of  the  penis  in  the  peno-scrotal 

Fig.  220. 


r~. 


C— 


Epispadias.  NGlaton's  operation.  A.  Abdominal  flap.  B.  Urethral  infundib- 
n In nt .  ('.  ('.  Lateral  incisions  at  junction  of  skin  and  mucous  membrane.  F,  F. 
Scrotal  incisions  circumscribing  O,  the  scrotal  flap. 


angle,  the  other  at  a  distance  below  the  first  equal  to  the 
length  of  the  penis,  and  is  left  adherent  at  both  ends. 
After  the  flap  has  been  dissected  up,  the  penis  is  passed 
under  it,  bringing  the  raw  surface  of  the  reversed  abdom- 
inal flap  into  contact  with  that  of  the  scrotal  flap,  and  the 
great  circumference  of  the  latter  is  fastened  by  three  su- 
tures to  the  outer  lips  of  the  two  incisions  made  along  the 
sides  of  the  urethral  gutter. 

The  canal  thus  formed  is  very  large,  and  both  Nelaton 
and  Dolbeau  found  it  necessary  to  diminish  its  size  by  ap- 


490     GENFTO-UBINABY  ORGANS  OF  THE  MALE. 

plying  the  actual  cautery  to  its  interior.  The  operation 
devised  by  Thiersch  is  generally  deemed  superior. 

Thiersch's  Method.1 — This  operation  requires  several 
months  for  its  completion,  since  it  is  composed  of  four  dis- 
tinct operations  performed  at  different  times.  In  order  to 
prevent  the  urine  from  coming  into  contact  with  the  raw 
surfaces  of  the  flaps  Thiersch  makes  an  opening  into  the 
urethra  through  the  perineum  and  maintains  it  during  the 
entire  period  of  treatment. 

First  Step.  (Fig.  221.) — Creation  of  the  meatus  and 
the  portion  of  the  canal  occupying  the  glans.  The  sur- 
geon makes  a  deep  incision  along  each  side  of  the  urethral 
groove  in  the  glans,  pares  the  surface  of  the  outer  lip  of 


A        a 

Epispadias.  Thiersch's  operation,  l.  The  glans  seen  from  above.  A,  A.  The 
incision  on  each  side  of  the  gutter  C.  B,  B.  The  freshened  surface.  2.  'I' runs  verso 
sect  inn  of  glans  Bhowingtheincisimis.  :;.  The  freshened  surfaces  brought  together 
and  closing  in  the  urethra  U. 

each  incision,  brings  the  freshened  surfaces  into  contact, 
and  fixes  them  with  two  or  three  points  of  twisted  suture. 
8e(X)ND  Step.  (Figs.  222,  223.) — Creation  of  the  ure- 
thra along  the  body  of  the  penis.  The  surgeon  makes  an 
incision  through  the  skin  and  subcutaneous  tissue  at  the 
edge  of  the  urethral  gutter  on  the  right  side,  makes  a 
short  transverse  cut  outward  from  each  end,  and  dissects 
up  the  rectangular  Hap  thus  marked  out.  On  the  left 
side  he  makes  a  longitudinal  incision  one  centimeter  ex- 
ternal to  the  edge  of  the  gutter,  and  a  transverse  incision 
from  each  end.  This  flap  is  dissected  up,  making  it  as 
thick'  as  possible,  and  turned  over  so  as  to  form  a  roof  for 

i  Aivhiv  fiir  Beilkunde,  1869.  pp.  20-36,  and  Langenbeck's  Archiv, 
Vol.  XV..  Pari  II.,  I-.  379. 


EPISPADIAS. 


491 


the  urethral  gutter,  its  cutaneous  surface  directed  down- 
ward, its  raw  surface  upward.  Several  ligatures  are 
passed  through  it  near  its  free  border  and  then  through 
the  base  of  the  right-hand  flap,  and  the  latter  drawn 
across  the  former  so  that  their  raw  surfaces  are  brought 
into  contact  throughout.  The  free  edge  of  the  right  flap 
is  then  fastened  to  the  skin  forming  the  outer  edge  of  the 
incision  on  the  left  side. 

Third  Step. — To  close  the  gap  remaining  between  these 

two  new  portions  of  the  urethra.     A  transverse  incision 

is  made  in  the  prepuce,  the  glans 

Fig.  222.  passed  through  it,  the  borders  of  the 

gap  pared  and  fastened  to  the  edges 

of  the  incision  in  the  prepuce. 

Fourth  Step. — To  close  the  pos- 
terior portion  of  the  canal  or  infun- 

Fig.  223. 


Epispadias.    (Thiersch.) 

Second  step.     Incisions  lim- 
iting the  two  lateral  flaps. 


Epispadias.     (Thiersch 
of  penis,  showing  flaps. 


Transverse  section 


dibulum.  The  method  employed  is  similar  to  that  used 
in  the  second  step  of  the  operation,  the  flaps  being  taken 
from  the  groins.  The  left  flap  has  the  form  of  an  isosceles 
triangle,  and  its  base  occupies  the  left  half  of  the  upper 
semi-circumference  of  the  opening ;  it  is  turned  over  so 
that  its  cutaneous  surface  is  directed  downward,  and  its 
free  border  is  united  to  the  freshened  posterior  edge  of  the 
roof  of  the  new  urethra.  The  other  flap  is  quadrilateral, 
its  base  corresponds  to  the  right  inguinal  ring,  and  it  is 


492      GEXITO-URWARY  ORGANS  OF  THE  MALE 

drawn  over  the  first  one  so  that  their  raw  surfaces  are 
brought  into  contact  and  fastened  together  with  sutures. 
Finally,  the  fistula  established  in  the  perineum  is  closed. 

HYPOSPADIAS. 

The  deformity  known  as  hypospadias  is  characterized 
by  a  congenital  abnormal  opening  of  the  urethra  upon  the 
under  surface  of  the  penis.  Sometimes  the  urethra  ends 
at  the  abnormal  opening,  sometimes  it  is  continued  more 
or  less  imperfectly  beyond  it  either  in  the  form  of  a  tube, 
which  is  usually  imperforate  at  one  or  two  points,  or  in 
that  of  a  gutter.  The  varieties  of  hypospadias  are  usu- 
ally classified  in  three  groups,  the  balanitic,  penile,  and 
scrotal,  according  as  the  abnormal  opening  is  found  at  a 
point  in  the  urethra  corresponding  to  the  glans,  the  pen- 
dulous portion  of  the  penis  or  the  scrotum.  The  balanitic 
is  the  most  frequent  and  least  important,  and  the  penile  is 
less  frequent  and  less  important  than  the  scrotal.  The 
defect  never  extends  further  back  than  the  bulb  of  the 
urethra,  and  consequently  never  causes  incontinence  of 
urine.  In  the  scrotal  and  in  some  of  the  penile  varieties 
the  anterior  portion  of  the  urethra  forms  a  tense  fibrous 
cord  binding  down  the  glans,  curving  the  body  of  the 
penis  upward,  and  preventing  its  erection. 

In  the  balanitic  variety,  when  the  anterior  portion  of 
the  urethra  exists  in  the  form  of  a  gutter,  no  treatment  is 
required  unless  the  opening  is  too  small.  The  slight  defi- 
ciency in  length  involves  no  loss  of  function,  and  attempts 
to  reconstitute  the  defective  portion  of  the  canal  by  some 
plastic  operation  usually  fail.  In  fact,  if  the  canal  exists 
between  the  meatus  and  the  abnormal  opening,  it  may  be 
better  to  slit  it  up  than  to  try  to  close  the  latter. 

The  scrotal  variety  is  considered  irremediable,  and  has 
never  been  the  subject  of  surgical  interference.  In  it  the 
scrotum  is  bifid,  the  penis  usually  very  small,  and  the 
urethral  orifice  at  the  bottom  of  an  iiifiindibulum  resem- 
bling a  vulva.  Individuals  thus  deformed  have  often  been 
mistaken  for  hermaphrodites  and  sometimes  for  females. 

In  the  penile  variety,  when  the  anterior  portion  of  the 


HYPOSPADIAS.  493 

urethra  is  normal,  the  opening;  may  be  closed  l>y  freshen- 
ing the  surface  about  its  edge  and  covering  it  with  a  flap 
taken  from  the  adjoining  skin.  When  the  anterior  por- 
tion exists  only  in  the  form  of  a  more  or  less  shallow 
groove,  it  may  be  transformed  into  a  complete  canal  by 
one  of  the  methods  of  urethroplasty  hereinafter  described. 
The  two  other  modes  of  operating,  urethrorrhaphy  and 
perforation,  have  now  been  discarded  ;  in  the  former  the 
edges  of  the  groove  were  pared  and  brought  together 
with  sutures,  in  the  latter  a  trocar  was  passed  along 
through  the  tissues  of  the  under  side  of  the  penis  from 
the  extremity  of  the  glans  to  the  abnormal  opening  of 
the  urethra,  and  the  route  thus  created  kept  open  by  the 
frequent  passage  of  sounds. 

If  the  penis  is  incurvated  it  must  be  straightened  as  a 
preliminary  to  auy  operation.  To  accomplish  this  it  is 
not  sufficient  to  divide  only  the  fibrous  band  on  its  under 
surface,  for  the  retraction  is  partly  maintained  by  the 
shortness  of  the  inferior  portion  of  the  sheaths  of  the 
corpora  cavernosa  and  the  septum  between  them.  If  the 
skin  on  the  under  surface  is  flexible  enough  to  allow  the 
penis  to  be  straightened  after  the  internal  bands  have 
been  divided,  this  division  may  be  made  subcutaneously, 
following  the  example  of  Bouisson,  by  introducing  a  teno- 
tome and  pressing  its  edge  against  the  sheath  of  the  cor- 
pora cavernosa  and  the  septum  while  the  glans  is  drawn 
steadily  away  from  the  scrotum.  Ordinarily,  however, 
this  is  not  possible,  and  one  or  two  transverse  incisions 
one  centimeter  long  must  be  made  through  the  skin  and 
deeper  parts.  By  the  straightening  of  the  penis  these 
transverse  incisions  are  transformed  into  longitudinal  ones, 
and  their  sides  are  then  drawn  together  by  sutures. 
Several  months  must  then  be  allowed  to  elapse  before  the 
subsequent  plastic  operation  is  undertaken,  in  order  that 
the  cicatrix  may  become  perfectly  soft  and  attain  its  full 
vitality. 

In  the  earlier  operations  of  urethroplasty  the  floor  of  the 
urethra  was  formed  by  a  long  narrow  vertical  flap  taken 
from   the   scrotum,   its    base  adjoining   the   orifice   of  the 


494      GENITO-URINARY  ORGANS  OF  THE  MALE. 

urethra,  and  its  borders  fastened  to  the  edges  of  two  lon- 
gitudinal incisions  on  the  under  side  of  the  penis.  In 
short,  the  method  resembled  that  already  described  as  em- 
ployed by  Nelaton  for  the  relief  of  epispadias,  even  to  the 
reinforcement  of  the  flap  by  a  transverse  one  taken  from 
the  skin  above  the  root  of  the  peuis.  The  results  of  these 
attempts  were  so  unsatisfactory  that  Avhen  Nelaton  was 
consulted  in  1872,  concerning  a  patient  affected  with 
hypospadias,  he  advised  that  nothing  should  be  done, 
saying  that  he  had  made  many  canals  through  which  the 
urine  was  carried  to  the  end  of  the  penis,  but  they  inter- 
fered with  erection,  and  did  not  facilitate  fecundation.1 
The  surgeon  who  received  this  advice,  Theophile  Anger, 
thereupon  devised  another  method,  ignorant  that  a  similar 
one  had  been  employed  shortly  before  by  Thiersch  in 
epispadias  and  by  Scymanowski  for  urethral  fistula,  and, 
having  put  it  into  execution,  obtained  an  excellent  result. 

Theopile  Anger's  Method. — In  this  case  the  urethral 
opening  was  at  the  penoscrotal  angle,  the  anterior  portion 
of  the  canal  was  entirely  lacking,  and  the  penis  was  so 
curved  that  the  extremity  of  the  glans  was  not  more  than 
half  an  inch  from  the  opening.  The  penis  was  first 
straightened  by  two  short  transverse  incisions  carried  to 
such  a  depth  that  the  corpora  cavernosa  were  exposed  at 
the  bottom  of  the  wound  ;  the  bleeding  was  slight,  and  the 
wound  healed  promptly.  The  plastic  operation  was  per- 
formed nearly  four  months  afterward,  and  was  only  par- 
tially successful,  the  posterior  portion  of  the  flap  disap- 
pearing by  absorption.  A  second  operation  six  months 
later,  was  entirely  successful,  and  the  condition  of  the 
parts,  when  the  patient  was  shown  to  the  Societe  de  Chi- 
purgie  five  mouths  afterward,  was  entirely  satisfactory  ;  the 
tissues  were  supple,  there  was  no  stricture  in  the  canal, 
and  erection  was  perfect,  except  for  a  very  slight  incurva- 
tion downward. 

The  first  plastic  operation  was  as  follows  :  An  incision, 
extending    from    the   glans    to    the    scrotum,  was    made 

'Theophile  Anger  in  Bull,  de  la  Soc.  <l»-  Chirurgie,  Beance  ilu  '_'l 
Janvier,  1874. 


HYPOSPADIAS. 


495 


through  the  skin  on  the  left  side  parallel  to  the  median 
line  and  one  and  a-half  centimeters  from  it,  and  from  each 
extremity  of  this  an  oblique  incision  was  carried  to  the 
median  line,  the  posterior  one  ending  on  the  scrotum  just 
behind  the  urethral  opening  (Fig.  224).  The  cutaneous 
flap  circumscribed  by  these  three  incisions  was  dissected 
up  so  that  it  could  be  turned  back  with  its  epidermic  sur- 
face directed  inward,  and  thus  constitute  the  floor  of  the 

Fio.  224. 


Hypospadias.    Theophile  Anger's  method. 


oew  canal.  .V  second  longitudinal  incision  was  then  made 
a  little  to  the  right  of  the  median  line,  parallel  to  and  as 
long  as  the  first,  a  transverse  incision  one  and  a-half  to 
two  centimeters  long  carried  outward  from  each  end  of  it, 
and  the  flap  thus  circumscribed  dissected  up. 

A  sound  was  then  introduced  into  the  urethra,  the  first 
Hap  drawn  back  over  it,  and  six  sutures  placed  close  to  its 
free  longitudinal  border  ;  the  two  ends  of  each  suture  were 
then  attached  to  a  needle  and  carried  through  the  base  of 


496      GENITO-URINARY  ORGANS  OF  THE  MALE. 

the  second  flap  from  within  outward,  as  shown  in  the  fig- 
ure, drawn  tight,  and  fixed  by  pinching  a  tube  of  lead 
upon  them.  Finally,  the  second  flap  was  drawn  over  the 
first,  and  its  edge  made  fast  to  the  outer  lip  of  the  first  in- 
cision, thus  covering  in  all  the  raw  surface. 

Anger  tied  in  the  catheter  and  left  it  for  several  days, 
but  admits  that  this  was  a  mistake.  When  he  repeated 
the  operation  he  left  the  catheter  in  for  only  twenty-four 
hours,  and  then  reintroduced  it  only  when  the  urine  had 
to  be  drawn  off. 

Duplay's   Method. — The  operation    has  three   steps  or 


Hypospadias.    Duplay's  method, 

Stages.  In  the  first,  the  penis  is  straightened  and  a  meatus 
made;  in  the  second,  the  portion  of  the  urethra  which  is 
lacking  is  restored  ;  and,  in  the  third,  this  new  portion  is 
united  to  that  which  previously  existed. 

FlRST  STEP. — The  penis  is  straightened  by  transverse 
or  subcutaneous  incisions  as  before  described,  and  the 
meatus  made  by  paring  a  strip  of  the  surface  of  the  glans 
on  each  side  of  the  groove  representing  the  urethra,  and 
bringing  them  together  with  one  or  two  points  of  twisted 
SUture  over  a  piece  of  gum  catheter  placed  in  the  groove. 
If  necessary,  the  groove  may  be  deepened  by  one  or  two 
longitudinal  incision-  on  its  floor  (roof  of  the  urethra). 


URETHRAL   FISTULA.  497 

Second  Step. — Two  longitudinal  incisions,  extending 
from  the  glans  nearly  to  the  abnormal  urethral  opening, 
are  made,  one  on  each  side  of  the  median  line,  at  a  dis- 
tance from  each  other  equal  to  the  circumference  to  be 
given  to  the  new  urethra  ;  and  from  each  end  of  these  a 
short  transverse  incision  is  made  toward,  but  not  quite  to, 
the  median  line  (Fig.  '2'2o,  A).  The  rectangular  flaps 
thus  circumscribed  are  dissected  up  toward  the  median 
line,  turned  back  over  a  gum  catheter,  and  their  free  bor- 
ders fastened  together  with  sutures  (Fig.  22o,  B  and  ( ' ). 
The  outer  lips  of  the  two  incisions  are  then  loosened  suf- 
ficiently by  dissection  to  allow  them  to  be  drawn  over  the 
others  and  fastened  together  in  the  median  line  with  in- 
terrupted or  twisted  sutures.  Care  must  be  taken  to  at- 
tach the  anterior  ends  of  all  four  flaps  to  the  pared  sur- 
face of  the  glans,  so  that  the  new  urethra  may  be  contin- 
uous with  the  piece  previously  made. 

Third  Step. — To  close  the  gap  between  the  termina- 
tion of  the  old  and  the  beginning  of  the  new  portions  of 
the  urethra,  Duplay  freshened  the  edges  and  brought 
them  together  with  double  rows  of  sutures. 

URETHRAL  FISTULA. 

Urethral  fistula?,  as  a  rule,  are  more  difficult  to  close 
the  further  they  are  from  the  bladder.  Those  occupying 
the  perineum  and  scrotum  are  long,  pass  through  thick 
tissues,  and  will  usually  heal  spontaneously  if  the  full 
caliber  of  the  urethra  in  front  of  them  is  maintained. 
Occasionally  it  becomes  necessary  to  freshen  their  sides 
with  a  knife,  caustics,  or  cautery. 

Fistulas  occupying  the  pendulous  portion  of  the  penis 
have  but  little  tendency  to  close  spontaneously,  unless 
they  are  I'ecent  and  small ;  the  distance  between  the  mu- 
cous and  cutaneous  surfaces  is  so  short  that  the  walls  of 
the  fistula  cicatrize  promptly  without  uniting,  and  that 
renders  a  spontaneous  cure  practically  impossible.  Opera- 
tions undertaken  for  the  purpose  of  closing  them,  exclusive 
of  simple  cauterization,  are  divided  into  two  classes,  ure- 
throrrhaphy  and   urethroplasty.     In  the  former,  the  sides 


•±9S      GENITO-UEINABY  ORGANS  OF  THE  MALE. 

of  the  fistula  are  pared  and  brought  together  in  the  me- 
dian line  ;  in  the  latter,  the  loss  of  substance  is  made 
good  by  the  transfer  of  cutaneous  flaps. 

It  has  always  been  held  that  the  principal  obstacle  to 
the  closure  of  a  fistula  is  the  frequent  passage  of  urine 
through  it,  and  although  this  has  been  occasionally  ques- 
tioned, especially  with  reference  to  normal  urine,  it  is  still 
considered  one  of  the  principal  indications  to  prevent  this 
passage.  The  choice  lies  between  three  methods  :  1st,  In- 
troducing a  catheter  and  drawing  off'  the  urine  as  often  as 
it  becomes  necessary  to  empty  the  bladder  ;  2d,  tying  in 
a  catheter ;  3d,  establishing  a  free  passage  for  the  urine 
at  some  point  on  the  proximal  side  of  the  fistula.  The 
first  two  methods  are  open  to  serious  objections  ;  the  fre- 
quent passage  of  the  catheter  is  calculated  to  disturb  the 
adjustment  of  the  flaps,  stretch  the  sutures,  and  irritate  the 
urethra  ;  and,  moreover,  a  small  quantity  of  urine  is  sure 
to  escape  through  the  canal  beside  or  behind  it.  A  cath- 
eter retained  in  the  urethra  for  several  days  is  even  worse  ; 
as  Ducamp  l  pointed  out  more  than  fifty  years  ago,  it  vio- 
lates the  two  conditions  necessary  to  the  cicatrization  of 
every  wound,  moderate  degree  of  inflammation  and  of 
humidity,  by  irritating  the  canal  and  provoking  an  exces- 
sive flow  of  mucus.  After  two  or  three  days  at  the  latest 
it  not  only  fails  to  remove  the  urine  as  fast  as  it  collects  in 
the  bladder,  but  actually  favors  its  escape  alongside  and 
through  the  wound.  It  excites  cystitis  of  the  vesical 
neck,  and  sooner  or  later  gives  rise  to  the  complex  of 
symptoms  known  as  urinary  fever.  In  short,  it  is  not 
only  inefficient  after  the  first  day  or  two,  but  is  positively 
harmful.  The  objection  to  the  third  method,  unless  a 
perineal  fistula  exists  and  can  be  sufficiently  enlarged,  is 
that  as  usually  practised  it  involves  an  additional  and 
considerable  wound  in  the  perineum. 

Urethrorrhaphy. — This  term  is  applied  to  the  simple  ap- 
proximation of  the  sides  of  a  fistula  after  they  have  been 
pared.     Verneuil 2  considers  the  method  applicable  to  all 

lTraite"  des  Retentions  d'Urfne,  ]825,  p.  237;  quoted  by  Verneuil. 
2('liJi-iiiL'ii-  Reparatrice,  p.  B90i 


URETHRAL  FISTULA.  499 

circular  fistulse  not  more  than  one-fifth  of  an  inch  in  diam- 
eter if  the  surrounding  tissues  are  thick,  and  also  to  ob- 
long fistulre  of  much  greater  size  when  their  long  axis  is 
in  the  median  line  and  their  sides  can  be  easily  brought 
together.  He  thinks  the  numerous  failures  which  have 
followed  the  use  of  the  operation  have  been  caused  by  a 
lack  of  attention  to  details,  and  he  suggests  that  the  par- 
ing of  the  edges  should  be  oblique  so  as  to  give  the  fistula 
the  form  of  a  funnel  with  its  apex  at  the  opening  into  the 
urethra,  the  mucous  membrane  of  which  should  not  be  in- 
cluded in  the  paring.  Fine  metallic  sutures  should  be  used, 
applied  at  short  intervals,  not  penetrating  to  the  canal  of  the 
urethra,  and  tied  over  a  leaden  plate  on  the  surface.  The 
line  of  reunion  should  be  longitudinal,  not  transverse,  and 
if  primary  union  is  not  obtained  the  sutures  should  be  re- 
tained to  favor  secondary  union.  During  the  operation  a 
sound  should  be  kept  in  the  urethra  in  order  that  the 
canal  may  have  its  full  size. 

Urethroplasty. — The  methods  that  have  been  suggested 
and  employed  have  been  very  numerous,  but  most  of  them 
count  more  failures  than  successes.  This  is  especially 
true  of  those  by  which  longitudinal  or  transverse  flaps 
have  been  dissected  up  on  opposite  sides  of  the  fistula,  and 
brought  together  by  their  edges  across  its  center,  for  the 
tissues  are  usually  too  thin  to  afford  a  sufficiently  broad 
surface  of  coaptation,  and  the  urine  finds  its  way  at  once 
through  the  wound.  It  has  been  proposed  to  overcome 
the  latter  obstacle  to  union  by  passing  a  piece  of  thin 
India-rubber  under  the  flaps,  but  it  is  doubtful  if  the 
presence  of  the  foreign  body  would  not  have  a  more  un- 
favorable effect  upon  the  thin,  delicate  flaps  than  the  urine 
which  it  is  designed  to  keep  away. 

Nilaton's  Method. — Nelaton  pared  the  edges  of  the 
fistula  and  dissected  up  the  skin  subcutaneously  for  about 
an  inch  around  it  by  entering  the  knife  through  a  short 
transverse  incision  below  it.  The  skin  thus  liberated  was 
pinched  up  in  a  longitudinal  fold  along  the  median  line, 
and  fixed  in  this  position  by  twisted  or  quilted  sutures. 

Meybard  made  the  dissection  through  the  fistula,  thus 


500     QENITO-URINABY  ORGANS  OF  THE  MALE. 

avoiding  the  transverse  incision  of  the  skin.  Dieffenbaeh 
and  Ddore  employed  a  similar  method,  but  instead  of  dis- 
secting up  the  skin  subcutaneously  they  raised  two  longi- 
tudinal or  transverse  flaps  and  fastened  them  together  by 
their  raw  and  under  surfaces  (not  edges)  in  the  center,  the 
former  passing  his  sutures  through  a  leather  splint  on  each 
side,  the  latter  applying  them  in  three  rows,  one  above  the 
other. 

Ddpeeh  and  AUiot  dissected  up  a  single  flap,  drew  it 
entirely  across  the  fistula,  and  fastened  it  to  a  raw  surface 
prepared  upon  the  opposite  side. 

Sir  Astley  Cooper  cut  away  the  skin  in  such  a  manner 
as  to  leave  a  raw  surface  of  quadrilateral  form  with  the 
fistula  in  its  center,  and  then  covered  it  with  a  flap  of  the 
same  shape,  taken  from  the  scrotum  by  the  Indian 
method  of  antoplasty. 

Arlaud1  obtained  a  complete  success  in  a  remarkable 
case,  where  the  urethra  had  been  completely  divided  just 
in  front  of  the  peno-scrotal  angle,  and  its  two  cut  ends 
were  nearly  an  inch  apart,  by  adapting  a  method  previ- 
ously employed  by  Roux  to  close  a  fistula  in  the  trachea. 
The  principle  is  the  same  as  in  Delpcch's  method,  the 
difference  in  detail  being  that  two  Haps  are  used  instead 
of  only  one;  the  second  one,  that  which  has  its  cutaneous 
surface  pared,  being  drawn  under  the  first. 

Two  transverse  flaps,  one  in  front  of  the  fistula,  the 
other  behind  it,  were  marked  out  by  longitudinal  inci- 
sions four  centimeters  apart  ;  the  anterior  one  was  dis- 
sected up  for  a  distance  of  two  centimeters  toward  the 
glans,  and  the  posterior  one  dissected  back  over  the 
scrotum,  until  it  could  be  easily  drawn  forward  far 
enough  to  cover  the  fistula  entirely.  The  anterior  por- 
tion of  the  cutaneous  surface  of  the  second  (scrotal)  flap 
was  tli'ii  thoroughly  pared,  the  flap  drawn  forward  so  as 
to  cover  the  fistula,  and  the  anterior  flap  draw  n  back  over 
the   other  and    fastened    then'    by    four   points   of  twisted 

suture. 

'Dull,  de  la  Sni'ii'ii'  de  Chlrurgie,  1857,  p,  550,  and  Vemeuil's  Chi- 
rurgie  B^paratrice,  p.  65 1. 


URETERAL  FISTULA.  :'"l 

St'ilillot  dissected  up  a  small  flap  on  each  side,  its  base 
adjoining  the  edge  of  the  fistula,  its  free  border  directed 
outward,  reversed  and  united  them  by  their  free  borders 
in  the  median  line  (their  epithelial  surfaces  directed  in- 
ward), and  brought  the  sutures  out  through  the  meatus. 
The  raw  surface  of  the  flaps  was  then  covered  by  a  third 
flap  transferred  by  the  Indian  method,  or  by  sliding. 

I!i(/(iii(l  closed  a  large  fistula  at  the  peno-scrotal  angle 
by  the  method  already  described  as  Xelaton's  method  of 
treating  epispadias.  He  took  a  quadrilateral  median  flap 
from  the  scrotum,  its  base  adjoining  the  fistula,  turned  it 
forward  over  the  fistula,  and  covered  its  raw  surface  with 
two  flaps  taken  from  the  sides  and  drawn  together  to 
meet  in  the  median  line. 

TheophUe  Anger  has  likewise  proposed  to  close  urethral 
fistulaeby  the  method  he  employed  so  successfully  in  a  case 
of  hypospadias  ;  and 

Scymanowski '  reports  a  success  obtained  by  a  method 
which  differed  but  slightly  from  Anger's.  He  made  the 
flaps  much  longer  than  the  fistula,  and  freshened  the  cu- 
taneous surface  of  the  reversed  flap  by  blistering  it,  so  that 
it  could  unite  with  the  raw  surface  upon  which  it  was  laid. 

Dr.  MeBurney,  by  the  use  of  methods  similar  to  the  last 
named,  has  obtained  a  number  of  brilliant  successes  in 
urethral  fistula  and  hypospadias ;  several  of  the  cases  are 
reported  in  the  proceedings  of  the  New  York  Surgical 
Society  between  1881  and  1884.  In  cases  in  which  pre- 
vious operations  had  failed  and  had  left  cicatricial  tissue 
about  the  opening  he  sought  to  close,  he  first  removed  the 
cicatricial  tissue  and  supplied  its  place  with  flaps  taken 
from  the  adjoining  skin.  To  close  the  openings  he  used 
flaps  similar  to  Anger's  (Fig.  224),  leaving  the  epidermis 
upon  the  surface  of  the  one  first  turned  in  over  an  area 
corresponding  exactly  to  the  opening,  and  freshening  with 
the  knife  all  the  remaining  portion  of  its  surface.  He  also 
dissected  up  for  a  line  or  two  the  anterior  edge  of  the  central 
unfreshened  portion  and  tucked  it  under  the  freshened 
anterior  margin  of  the  opening. 

1  Handbuch  der  Operativen  Cbirurgie,  1870. 


502     GEMTO-TJMNAMY  ORGANS  OF  THE  MALE 

INTERNAL  URETHROTOMY. 

Every  antiseptic  precaution  is  necessary.  .V  stricture  in 
the  penile  urethra  is  conveniently  divided  under  cocaine  by 
the  Otis  urethrotome  up  to  any  desired  size;  the  bladder 
may  then  be  washed  with  a  sterilized  saturated  solution  of 
boric  acid,  about  four  ounces  of  which  are  left  in.  The 
passage  of  full-sized  sounds  must  be  kept  up  subsequently. 

For  anterior  strictures  too  tight  to  admit  this  urethra- 
tome,  and  for  deep  strictures,  with  the  observance  of  cer- 
tain precautions,  the  instrument  of  Maisonneuve  is  very 
useful.  The  flexible  filiform  bougie  is  passed  through  the 
stricture  and  secured  to  the  staff,  which  then  follows  the 
bougie  into  the  bladder,  and  the  stricture  is  divided  by 
slipping  the  knife  along  the  whole  length  of  the  groove 
while  the  penis  is  drawn  nut  on  the  staff  to  straighten  and 
render  tense  the  urethra,  care  being  taken  t<>  make  the  sec- 
tion exactly  in  the  median  line  of  the  roof.  The  knife  is 
blunted  on  its  summit  and  is  supposed  to  divide  only  the 
narrowed  portions  of  the  canal.  After  a  stricture  beyond 
four  and  a-half  inches  from  the  meatus  has  been  cut  in  this 
way,  the  patient  is  placed  in  a  lithotomy  position,  the  per- 
ineal region  thoroughly  disinfected  and  shaved,  and  a 
broadly-grooved  staff,  about  the  size  of  a  No.  2s-:{(>  F. 
sound,  i-  passed  to  the  bladder.  It  is  so  held  in  the 
median  line  by  an  assistant  a-  to  make  the  curved  part  of 
the  staff  prominent  in  the  perineum.  RfcBurney's  gorget 
(  Fig.  226),  with  the  knife  protruded,  i-  then  plunged  into 
the  center  of  the  perineum,  opening  the  membranous  ure- 
thra and   striking  the  gi ve   in  the  staff,  into  which  the 

gorget  i-  pushed,  sheathing  the  knife  which  is  then  with- 
drawn, whileat  the  same  time,  by  -lightly  tilting  the  stall' 
and  advancing  the  gorget,  the  latter  -lip-  into  the  bladder 
as  evidenced  by  the  gush  of  urine.  A  soft-rubber  catheter 
i-  inserted  into  the  bladder  on  the  gorge!  through  the  peri- 
nea] puncture  and  retained  by  a  -ilk  suture  through  the 
-kin.  ami  the  gorgel  is  withdrawn.  The  bladder  and  ure- 
thra are  thoroughly  irrigated  with  a  saturated  solution  of 
boric  acid,  and  the  catheter  connected  with  a  tube  termin- 


EXTERNAL  PERINEAL    URETHROTOMY. 


503 


utility  beneath  the  surface  of  a  1 :  GO  solution  of  carbolic  acid 
in  a  bottle  under  the  bed.  A  slight  dressing  retained  by 
a  split  f-bandage  around  the  catheter  is  sufficient,  and  at 
the  end  of  five  days  a  sound  is  passed  through  the  whole 
length  of  the  urethra  entering  the  bladder  alongside  of  the 

Fig.  22G. 


McBiirney's  gorget  and  grooved  sound. 

catheter,  which  if  all  goes  well,  is  removed  twenty-four 
hours  later,  and  a  single  antiseptic  pad  placed  on  the 
punctured  wound  in  the  perineum. 

When  the  bladder  and  urine  are  not  extensively  dis- 
eased and  there  are  no  other  complications,  such  as  mul- 
tiple fistula?,  this  method  of  treating  deep  strictures  is 
generally  preferred  to  the  usual  external  urethrotomy. 


EXTERNAL  PERINEAL   URETHROTOMY. 
A.     With  a   Guide. — Prof.  Syme,    who    introduced 
this  operation,  employed   as  a  guide  a  staff,  the  straight 


504      GENITO-UMINARY  ORGANS  OF  THE  MALE. 

portion  of  which  was  of  full  size,  and  its  curved  portion 
much  smaller  and  grooved  on  the  convexity.  The  change 
from  the  full  to  the  small  size  was  abrupt,  not  gradual 
(Fig.  227).  This  instrument  has  been  superseded,  in  the 
United  States  at  least,  by  the  tunnelled  instruments  in- 
troduced by  Van  Buren,1  which  are  passed  into  the  blad- 
der over  a  tine  whalebone  bougie  as  a  guide,  the  beak  of 
the  instrument  being  bridged  over  or  drilled  out  for  a 
distance  of  about  one-quarter  of  an  inch,  so  that  it  can 
be  slipped  over  the  bougie  (Fig.  228).  If  a  Synic's  staff 
or  a  tunnelled  catheter  cannot  be  had,  any  instrument  may 
be  used  which  can  be  got  into  the  bladder,  but  it  is  a  great 
advantage  to  be  able  to  pass  a  full-sized  instrument  step 
by  step  as  the  stricture  is  divided. 

The  patient  is  placed  in  the  lithotomy  position  (dorsal 
decubitus,  thighs  flexed  upon  the  abdomen),2  the  perineum 
shaved,  the  whalebone  guide  introduced  into  the  bladder, 
a  tunnelled  silver  catheter  of  full  size,  grooved  on  the  con- 
vexitv,  passed  down  over  it  to  the  stricture  and   confided 

Fig.  227. 


Syme'.s  shift' for  perineal  -ci-tioii. 

to  an  assistant,  who  also  draws  the  scrotum  forward  out 
of*  the  way.  An  incision,  varying  in  length  according  to 
the  position  of  the  stricture,  is  made  in  the  median  line, 
and  the  end  of  the  catheter  exposed.  If  the  stricture  i< 
deeply  placed  the  sides  of  the  incision  must  now  be  held 
apart,  while  the  guide  is  carefully  followed  from  before 
backward  with  short,  cautions  strokes  of  the  knife  in  the 
median  line,  and    the    catheter   pushed   along  as  the  route 

1  \';ui  Buren  and  Keyes,  Genito-Urinary  l>isc;is«s,  p.  127. 

'  \  convenient  method  of  keeping  the  thighs  6xed  is  to  puss  m  stent 

cane  under  tin-  knee  and  fasten  it  with  :i <1  or  roller  bandage  pasa  ■  ! 

fron tend  around  the  patient's  neck  to  the  other  end.  An  instru- 
ment has  been  specially  constructed  i'm-  the  purpose  '  Fig.  229),  but  a 

jtOUl       tick    line-   verv    well. 


EXTERNAL   PERINEAL   URETHROTOMY 


505 


Fig.  228. 


is  opened,  until  the  posterior  limit  of  the  stricture  having 
been  passed,  it  slips  into  the  blad- 
der.     Care  must  be  taken  not  to 
divide  the  whalebone  guide  by  a 

careless  stroke  of  the  knife. 

[f  Syme's  staff  is  used,  the  in- 
cision is  carried  down  until  the 
groove  in  the  curve  of  the  staff 
can  be  felt  by  the  finger;  the 
handle  of  the  staff  is  then  grasped 
with  the  left  hand,  the  point  of 
a  narrow  bistoury  passed  into  the 
groove  behind  the  stricture,  and 
the  latter  divided  by  cutting  from 
behind  forward. 

Any  bands  that  are  found  on 
the  roof  of  the  urethra  must  be 
divided,  and  a  full-sized  steel 
sound  passed  to  make  sure  that 
the  stricture  has  been  thoroughly 
relieved. 

B.  Without  a  Guide. — The 
cases  are  rare  in  which  a  fili- 
form whalebone  bougie  cannot  be 
passed  through  a  stricture  which 
allows  urine  to  pass,  and  con- 
sequently external  urethrotomy 
without  a  guide  is  not  often  re- 
quired. The  patient  is  placed  in 
the  lithotomy  position,  the  perin- 
eum shaved,  and  a  full-sized 
sound,  preferably  grooved,  passed 
down  to  the  stricture  and  confided 
to  an  assistant,  who  also  draws 
the  scrotum  forward,  keeping  its 
raphe  exactly  in  the  median  line. 
An  incision,  two  and  a-half  to 
three  inches  long,  is  made  in  the 
median  line,  and  the  end  of  the        '""'S^gS! "d 


500     GENITO-UR1NARY  ORGANS  OF  THE  MALE. 

sound  exposed  by  opening  the  urethra  half  an  inch  in 
front  of  the  stricture.  The  sound  is  then  partly  with- 
drawn, the  sides  of  the  wound  held  widely  apart  by 
means  of  ligatures  passed  through  the  cut  edges  of  the 

Fig.  229. 


Clover's  crutch,  for  operations  upon  the  perineum. 


urethra,  and  an  effort  made  to  pass  a  fine  probe  or  whale- 
bone bougie  through  the  stricture  from  before  backward  ; 
if  the  effort  succeeds,  the  operation  becomes  one  "with  a 
guide,"  and  is  completed  as  before  described.  If  the 
probe  cau  be  passed  for  only  a  short  distance,  a  line  or 
two,  the  tissues  are  divided  upon  it,  and  the  attempt  re- 
newed until  the  canal  behind  the  stricture  is  reached. 
Success  depends  largely  upon  full  exposure  of  the  end  of 
the  stricture  in  order  that  the  search  for  the  opening  may 
be  aided  by  the  eye. 

[f  these  efforts  fail  entirely,  the  urethra  must  besought 


h'XSTL'oriiv  OF  THE  -BLADDER.  507 

for  behind  the  stricture — a  most  difficult  task  unless  ;i 
perineal  fistula  exists  through  which  a  guide  can  be  passed 
into  the  bladder,  or  unless  this  portion  of  the  urethra  is 
distended  with  urine  and  can  he  punctured  in  the  median 
line.  The  bottom  of  the  wound  should  be  freely  exposed 
by  retraction  of  the  sides,  the  index-finger  passed  well  into 
the  rectum  and  pressed  up  toward  the  center  of  the  pubic 
arch  as  a  guide,  and  the  wound  then  deepened  by  succes- 
sive cuts  directly  in  the  center.  After  the  urethra  has 
been  thus  opened  it  must  be  slit  forward  through  the 
stricture. 

Occasionally  surgeons  have  opened  the  bladder  above 
the  pubes  and  passed  a  sound  from  within  outward  to  the 
stricture  as  a  guide. 

EXSTROPHY  OF  THE  BLADDER. 

The  first  operation  for  the  relief  of  this  deformity  was 
performed,  according  to  Gross,  by  Prof.  Pancoast,  of 
Philadelphia,  in  1858;  according  to  Erichsen,  by  Dr. 
Daniel  Ayres,  of  Brooklyn,  in  1859.  The  deformity  is 
much  more  frequent  in  males  than  in  females,  and  the 
operative  indication  is  to  cover  in  as  much  as  possible  of 
the  exposed  mucous  membrane  and  facilitate  the  adapta- 
tion of  a  urinal  by  making  the  urine  escape  through  a 
comparatively  small  opening  ;  for,  as  the  sphincter  cannot 
be  restored,  there  will  always  be  incontinence.  The 
method  at  first  employed  was  the  same  as  Nelaton's  for 
epispadias  :  a  tegumentary  flap  was  raised  from  the  abdo- 
men above  the  bladder,  reversed  so  as  to  cover  the  latter, 
and  then  covered  itself  in  turn  by  lateral  flaps,  one  from 
each  side. 

The  first  flap  (Fig.  230)  should  be  square,  its  base  ad- 
joining and  slightly  broader  than  the  upper  margin  of  the 
opening,  its  length  should  be  sufficient  to  cover  in  the 
bladder  completely  when  turned  down  over  it.  A  pyri- 
form  flap  is  dissected  upon  each  side,  its  breadth  equal  to 
the  length  of  the  first  Hap,  and  its  base  directed  downward 
and  inward,  as  shown  in  Fig.  230,  or  downward  and  out- 


508      GEMTO-URWA&¥  ORGANS  OF  THE  MALI-:. 

ward  so  as  to  require  less  twisting  and  include  more  of 
the  cutaneous  branches  coming  from  the  femoral  artery. 
These  two  flaps  are  then  drawn  across  the  reversed  um- 
bilical flap,  meeting  in  the  median  line,  and  are  fastened 
to  each  other  with  twisted  sutures,  the  pins  including  a 
portion  of  the  thickness  of  the  umbilical  flap  also,  so  as 
to  keep  the  raw  surfaces  in  contact  (Fig.  231). 


Fig 


Fig.  231. 


Wood's  operation  fur  exstrophj 
bladder.    Incisions. 


Flaps  in  plac 


The  cducs  of  the  gaps  left  by  the  removal  of  the  flaps 
are  drawn  together  as  well  as  possible  with  twisted  and 
wire  sutures,  broad  strips  of  adhesive  plaster  applied  to 
give  support  and  relieve  tension,  and  the  patient  kept  in 
bed  in  a  sitting  posture  with  the  knees  drawn  up.  The 
sutures  may  be  removed  at  the  end  of  a  week.  Healing 
may  be  hastened  by  using  Thiersch  skin  grafts  on  granu- 
lating surfaces.  Of  late  years  many  other  devices  have 
been  tried,  some  of  them  with  gratifying  success. 

When  the  symphysis  is  absent  Trendelenburg  first  per- 
forms an  operation  to  remedy  tin;  epispadias.  Later  he 
divides  the  sacro-iliac  synchondrosis  on  each  side  from 
behind  forward,  sufficiently  to  mobilize  the  iliac  bones  and 

allow  the  gap  in    front  to  be   closed    by  pressing    together 

the  sides  of  the  pelvis.     Subsequently  the  margins  of  the 


t '.  I  THE Th'R IX.  I  Tin X.  509 

defect  in  the  soft  parts  are  freshened  and  brought  together 
with  sutures.  This  may  need  to  be  supplemented  by  a 
flap  operation  and  Thiersch  skin  grafts. 

Czerny,  starting  at  the  edges  of  the  detect,  frees  the 
wall  of  the  bladder  from  the  underlying  parts  and  sutures 
its  margins  together  to  form  a  closed  sac.  Then  this  is 
covered  in  by  two  lateral  flaps,  base  down,  as  in  the  first 
operation  described.  Afterward  the  neck  of  the  bladder 
and  the  freshened  edges  of  the  prostatic  portion  of  the 
urethra  are  brought  together,  and  then  the  epispadias  i> 
attended  to. 

Rutkowski  and  Mikulicz  l  have  successfully  used  a  por- 
tion of  the  intestine  to  enlarge  the  bladder,  and  in  a  few 
cases  the  ureters  have  been  transplanted  into  the  rectum 
or  colon. 

CATHETERIZATION  WITH  CURVED  METAL 
CATHETER). 

The  obstacles  to  the  passage  of  a  catheter,  exclusive  of 
stricture  and  of  false  passage,  are  found  either  at  the  tri- 
angular ligament,  in  the  membranous,  or  in  the  prostatic 
portion  of  the  urethra.  As  the  fixed  portion  of  the  canal 
begins  anteriorly  at  the  opening  in  the  subpubic  or  trian- 
gular ligament,  the  flaccid  pendulous  portion  in  front  of 
this  point  may  be  carried  aside  if  the  catheter  is  held  im- 
properly, and  doubled  upon  itself  in  front  of  the  beak  of 
the  instrument.  This  difficulty  is  overcome  by  drawing 
the  penis  gently  up  the  shaft  of  the  instrument  so  as  to 
straighten  out  the  portion  of  the  canal  yet  to  be  traversed, 
and  by  keeping  the  beak  in  the  median  line  and  making- 
it  follow  the  roof  rather  than  the  floor  of  the  urethra,  so 
as  to  avoid  especially  the  normal  pouch-like  dilatation 
found  on  the  under  side  just  in  front  of  the  opening  in 
the  ligament. 

The  obstacle  in  the  membranous  portion  is  caused  by 
the  spasmodic  contraction  of  the  muscles  which  envelop 
this  part  of  the  canal.     The  nature  of  the  obstruction  is 

1  Centralblatt  fur  Chir.,  18Q9.  Nog.  16and22. 


510     GENITO-UMINARY  ORGANS  OF  THE  MALE. 

recognized  by  the  tight  grasp  of  the  instrument  by  the 

muscles  and  the  quivering  of  the  fibers  transmitted 
tli rough   it  to   the  hand  of  the  surgeon.     The 

Fig.  232.  difficulty  is  overcome  by  making  gentle  pressure 
with  the  beak  of  the  catheter  in  the  proper  di- 
rection, so  as  to  tire  out  the  muscles. 

The  most  serious  obstacle  is  found  in  the  pro- 
static portion,  and  is  due  either  to  inflammatory 
swelling  of  the  mucous  membrane  or  of  the  gland 
(abscess  of  the  prostate),  or,  much  more  com- 
monly, to  senile  change  in  the  shape  and  size  of 
this  organ.  A  description  of  the  nature  of  these 
changes  and  lesions  does  not  come  within  the 
scope  of  this  work,  and  the  reader  is  referred  for 
them  to  special  treatises  upon  the  subject.  It  is 
sufficient  here  to  say  that  in  the  former  case  the 
inflammation  must  be  reduced  or  the  abscess 
evacuated  secundum  artem,  or,  failing  this,  the 
bladder  must  be  punctured  above  the  pubes,  or 
through  the  rectum.  In  the  other  case,  catheters 
of  different  curves  should  be  tried,  such  as  Mott's 
long  catheter  of  large  curve,  or  Mercier's  soft, 
single  or  double-elbowed  catheter.  It  is  also  well 
lo  pass  the  forefinger  of  the  left  hand  into  the 
rectum  to  make  sure  that  the  catheter  lias  en- 
tered at  the  apex  of  the  prostate,  and  that  it  has 
not  passed  out  of  the  canal  into  a  false  passage, 
and  to  try  to  lift  its  beak  over  the  obstacle  by 
making  direct  pressure  upon  the  curve  in  front 
of  the  prostate,  while  the  handle  is  simultane- 
ously depressed. 
Mercier'a       If  these  mean-  fail,  and    soft   instruments  of 

eathetered  •-'""  or  vwlca11!26^  rubber  cannot  be  introduced, 
the  bladder  must  lie  punctured. 
Passage    of   the    Catheter. — The    patient    having   been 

brought   to  the  side  of  the  bed  or    placed    upon    a    lounge, 

the  Burgeon,  standing  on  one  side,  separates  the  lips  of 
the  meatus  with  the  thumb  and  forefinger  of  the  left  hand, 
introduces  the  beak  of  the  catheter,  previously  well  warmed 


IATIIOLAPAXY.  -r>ll 

and  oiled,  and  passes  it  down  to  the  penoscrotal  angle, 
holding-  the  shaft  of  the  instrument  parallel  to  the  groin. 
He  then  sweeps  the  handle  around  to  the  median  line  of 
the  abdomen,  keeping  it  close  to  the  surface,  draws  the 
penis  gently  up  the  shaft,  and  presses  the  instrument 
bodily  downward  toward  the  feet  ;  as  soon  as  the  beak 
reaches  the  lower  border  of  the  symphysis  he  draws  the 
scrotum  up  and  presses  the  catheter  gently  onward,  still 
holding  it  parallel  to  the  body,  and  then  when  the  beak 
has  closely  approached  or  engaged  in  the  opening  in  the 
triangular  ligament  he  gradually  raises  the  handle,  brings 
it  forward  in  the  median  line,  and  depresses  it  between 
the  thighs.  Failure  to  enter  the  opening  in  the  triangular 
ligament  is  indicated  by  the  bulging  of  the  curve  of  the 
instrument  in  front  of  the  symphysis,  its  rebound  when 
the  slight  pressure  on  the  handle  is  removed,  and  the  mo- 
bility of  the  beak  when  the  handle  is  gently  rotated  about 
its  longitudinal  axis. 

As  the  shaft  passes  the  vertical  line  the  root  of  the 
penis  and  the  integument  covering  the  symphysis  should 
be  pressed  down  with  the  palm  of  the  hand  laid  broadly 
upon  it,  so  as  to  stretch  the  suspensory  ligament. 

PUNCTURE  OF  THE  BLADDER. 

Above  the  Pubes. — The  only  instrument  required  is  a 
straight,  or,  better,  a  curved  trocar  and  canula,  or  aspira- 
tor needle.  The  surgeon  satisfies  himself  by  percussion 
that  the  distended  bladder  rises  well  above  the  pubes,  and 
then  making  the  skin  tense  with  the  thumb  and  ringers  of 
his  left  hand,  he  plunges  in  the  trocar  close  above  the 
symphysis  pubis  in  the  median  line,  the  concavity  of  the 
instrument  turned  toward  the  bone. 

Some  surgeons  prefer  to  make  a  preliminary  incision  in 
the  median  line,  and  others  even  continue  the  use  of  the 
knife  until  the  bladder  can  be  felt  at  the  bottom  of  the 
wound. 

LITHOLAPAXY. 

It  is  the  operation  of  introducing  a  lithotrite  into  the 
bladder  through  the  urethra  and  with  it  crushing  a  stone 


512      GEXrrO-UBIXARY  ORGANS  OF  THE  MALE. 

into   fragments,    which  arc  then   removed   by   the    wash 
bottle  and  evacuators  represented  in  Fig.  236. 

The  modern  lithotrite  is  a  steel  instrument  consisting  of 
a  straight  shaft  eleven  inches  in  length,  having  at  one  end 
a  "  beak  "  about  an  inch  long  inclined  at  an  angle  of  from 
110°  to  130°,  and  at  the  other  a  cylindrical  roughened 
handle  containing  a  screw.  It  is  composed  throughout  of 
two  parts,  one  fitting  accurately  in  a  deep  groove  in  the 
other,  and  having  at  the  handle  a  male  screw  which  can 
be  thrown  into  and  out  of  gear  by  means  of  a  button  upon 


Fig.  233. 


sir  Henry  Thompson's  lithotrite. 


Fig.  2.34. 


the  other  part.  While  trying  to  catch  a  stone  the  screw 
should  be  out  of  gear,  in  order  that  the  male  blade  may 
lie  advanced  and  withdrawn  more  rapidly,  but  when  the 
stone  has  been  fairly  caught  the  button  must  be  pressed 
back  and  the  screw-power  u>((\  to  crush  it. 

Many  different   patterns  have   been  proposed    for  the 

beat  or  ja\\~  with  the  view  either  of  securing  the  thor- 
ough pulverization  of  the  fragments,  or  of  preventing  the 
clogging  of  the  instrument   l>v  the  impaction  of  the  inor- 


LITHOLAPAXY. 


513 


tar-like  detritus  between  the  jaws.  The  latter  difficulty 
can  be  overcome  by  leaving  the  jaw  of  the  female  blade 
entirely  open,  that  is,  with  a  large  fenestra  extending 
from  side  to  side  and  from  the  extremity  of  the  beak  to 
its  angle,  and  by  making  the  male  shaft  long  enough  to 
allow  its  jaw  to  be  passed  through  the  female  one.  In 
its  simplest  terms,  then,  the  jaws  should  consist  of  two 
parallel  bars,  one-fourth  of  an  inch  apart,  between  which 
a  third  one  fitting  loosely  in  the  gap,  can  be  forced. 

A  small  fenestra  at  the  angle  of  the  beak  will  not  pre- 
vent clogging,  although  it  may  diminish  it  if  there  is  a 
corresponding  projection  at  the  heel  of  the  male  jaw,  as  in 


Fig.  235. 


"  Scoop"  lithotrite. 

Fig.  235  ;  and  it  is  open  to  the  objection  that  it  may 
lodge  a  sharp  angular  fragment,  which,  projecting  beyond 
its  edges,  will  lacerate  the  neck  of  the  bladder  and  the  floor 
of  the  urethra  during  the  withdrawal  of  the  instrument. 

For  catching  and  crushing  small  fragments  the  "scoop" 
lithotrite  is  commonly  used;  the  jaw  of  its  female  blade 
is  broad  and  shallow,  with  no  fenestra  or  with  only  a 
small  one  at  its  angle.  The  edges  of  both  jaws  should  be 
bevelled,  and  the  male  considerably  narrower  than  the 
female,  so  that  they  may  be  brought  together  with  the 
least  possible  danger  of  including  a  fold  of  mucous  mem- 
brane between  them. 

Operation. — The  patient  is  anesthetized  and  placed 
upon  his  back,  with  his  hips  raised  upon  a  firm  pillow 
or  cushion  in   order  that   the  stone   may  gravitate  away 


•*>14      GENITO-TJRINABY   ORGANS  OF  THE  MALE. 

from  ths  Deck  of  the  bladder.  If  the  urine  is  turbid,  and 
especially  if  it  is  ammoniacal,  it  should  be  drawn  off  be- 
fore the  operation  and  the  bladder  thoroughly  washed 
with  a  borax  solution  (one  or  two  drachms  to  the  pint),  of 
which  from  two  to  four  ounces  should  be  left  in  the  blad- 
der to  facilitate  the  crushing.  The  surgeon,  standing  at 
the  patient's  right  side,  introduces  a  freshly  boiled  litho- 
tritc  after  greasing  the  instrument  with  vaseline.  Care 
must  be  taken  not  to  depress  the  handle  too  soon,  a  mistake 
which  is  likely  to  be  made  on  account  of  the  apparently 
great  depth  to  which  the  instrument  has  to  penetrate  be- 
fore the  bladder  is  reached. 

As  soon  as  the  instrument  has  entered  the  bladder,  it 
is  allowed  to  glide  across  it,  its  shaft  being  held  steadily 
in  one  position,  and  if  the  stone  is  free  it  will  generally 
be  touched  on  the  way.  The  surgeon  then  gently  turns 
the  beak  away  from  the  stone,  withdraws  with  his  right 
hand  the  male  blade  for  a  distance  determined  by  pre- 
vious measurement  of  the  stone,  presses  the  jaw  of  the 
female  blade  gently  against  the  floor  and  posterior  wall  of 
the  bladder,  rotates  the  beak  toward  the  stone,  and  closes 
the  male  blade  upon  it.  As  soon  as  the  stone  is  felt  to 
be  firmly  caught,  the  beak  is  rotated  back  to  the  vertical 
position,  and  the  screw  thrown  into  gear  by  pressing  back 
the  button  on  the  handle  with  the  thumb  of  either  hand. 
The  Iithotrite  with  the  stone  in  its  grasp  is  then  drawn 
away  from  the  posterior  wall  and  rotated  to  either  side 
to  make  sure  that  the  mucous  membrane  is  not  caught 
between  its  jaws,  and  then,  grasping  the  cylindrical 
handle  firmly  with  his  left  hand,  the  surgeon  crushes  the 
-tone  by  turning  the  screw  with  his  right,  and  continues 
this  action  until  the  register  upon  the  handle  shows  that 
tie  male  blade  has  been  driven  well  home.  The  screw 
i-  then  thrown  out  of  gear,  the  male  blade  drawn  back, 
the   beak    turned    again  toward    the   spot   where   the   stone 

was  caught,  and  the  instrument  closed  whether  the  frag- 
ments are  felt  or  not,  for  it  may  he  confidently  expected 
that  they  will  he  found  there. 

After  crushing  the  stone  in  this  manner  several  times 


LITHOLAPAXY 


515 


the  smaller  fragments  arc  washed  out  by  the  evacuating 
tube  and  washing-bottle  (Fig.  -}•"><>)  and  the  lithotrite  re- 
introduced ;  and  this  alternation  in  (he  use  of  the  instru- 
ments is  continued  until  the  bladder  is  emptied.  This 
frequent  washing  is  important   because  by  the  removal  of 


Evacuating-tube  unci  washius-bottli 


the  smaller  fragments  it  is  made  easier  to  seize  and  crush 
the  larger  ones. 

The  washing  is  done  as  follows  :  The  washing-bottle  is 

p  © 

filled  with  tepid  water,  then  the  tube  is  introduced,  and  as 
soon  as  the  urine  begins  to  flow  through  it  the  bottle  is 
coupled  to  it.  Or  the  coupling  may  be  done  just  before  the 
tube  has  entered  the  bladder,  and  the  air  in  the  tube  al- 
lowed to  rise  to  the  top  of  the  bottle,  by  turning  the  stop- 
cock, before  the  introduction  is  completed  and  the  washing 
is  begun. 

By  quick  compression  and  relaxation  of  the  rubber  bulb 
the  water  is  rapidly  forced  into  the  bladder  and  drawn  back 
again,  bringing  the  fragments  with  it  ;  these  fragments  sink 
to  the  bottom  of  the  bottle  and  are  not   returned  with  the 


516      GENITO-TJRINARY  ORGANS  OF  THE  MALE. 

returning  stream.  The  amount  of  water  driven  back  and 
forth  at  each  movement  will  vary  with  the  sensitiveness 
and  distensibility  of  the  bladder;  two  or  three  ounces  are 
sufficient  to  wash  effectively.  If  the  curved  tube  is  used, 
its  eye  should  be  in  turn  directed  to  different  quarters  of 
the  bladder  ;  if  the  straight  tube  with  a  square  end  is  used, 
it  must  be  passed  just  through  the  neck,  and  its  outer  end 
well  depressed  between  the  thighs. 

At  the  close  of  the  operation  the  surgeon  should  place 
his  ear  upon  the  hypogastrium  and  listen  while  washing,  to 
detect  the  click  against  the  tube  of  any  fragments  that 
may  remain.  This  is  a  more  delicate  test  than  the  use  of 
the  searcher. 

LITHOTOMY. 

The  anatomy  of  the  perineum  is  sufficiently  well  shown 
in  Fig.  237  to  render  a  detailed  description  unnecessary. 
The  dimensions  of  the  prostate  have  been  studied  with 
much  attention,  and  were  the  basis  of  many  of  the  modi- 
fications of  perineal  lithotomy,  for  it  has  been  held  that 
the  incision  should  not  be  carried  beyond  the  limits  of  the 
gland.  The  greatest  radius,  measuring  from  the  urethra, 
is  one  inclined  about  30°  backward  and  downward  from 
the  transverse  diameter,  and  in  the  normal  adult  prostate 
this  measures  about  three-quarters  of  an  inch  at  the  largest 
part  of  the  gland,  that  which  adjoins  the  neck  of  the 
bladder.  But,  as  the  diameter  of  the  prostate  diminishes 
:is  the  distance  from  the  bladder  increases,  an  incision 
which  remains  within  its  limits  at  one  point  may  extend 
far  beyond  them  at  another;  and  this  fact,  taken  in  con- 
oectioa  with  the  great  variations  in  the  size  of  the  gland, 
indicates  the  futility  of  attempts  to  regulate  the  incision 
with  mathematical  precision.  Fortunately,  the  depth  ofthe 
incision  is  not  a  measure  of  the  size  of  the  stone  which  can 
In'  safely  removed  through  it,  for  the  neck  of  the  bladder 
and  the  prostatic  portion  of  the  urethra  are  normally  di- 
latable to  a  diameter  of  nearly  an  inch. 

If  the  Stone  is  Large  and  the  traction  made  with  too 
much  force,  the  neck  of  the   bladder  may  be  torn  off,  but 


LITHOTOMY 


517 


more  commonly  the  incision  is  Lengthened  by  tearing  at 
its  outer  end,  an  accident  which  is  less  dangerous  than 
extending  the  incision  with  the  knife  would  be,  for  it 
spares  the  rich  plexus  of  veins  about  the  prostate. 


Fig.  2:;:. 


Avtery  of  corpus  cavernosum 
Dorsal  artery  of  penis 


A  rtery  of  bulb. 
Internal  piiriic  artery 


Cowper's  gland 


A  view  of  the  jirisit ion  of  the  viscera  at  the  outlet  of  the  pelvis. 

Lateral  Lithotomy. — The  instruments  required  are  a 
staff  with  a  long  curve,  deeply  grooved  on  its  convexity 
(Fig.  238),  a  stout  scalpel  with  a  cutting  edge  of  one  and 
one-half  inches  (Fig.  239),  a  Blizard's  knife  (Fig.  240), 
a  blunt  gorget  (Fig.  241),  if  the  patient  is  fat,  a  scoop 
(Fig.  242),  forceps  of  different  patterns  (Figs.  243,  244, 
245),  a  syringe  and  tube  for  washing  out  fragments,  and 
a  shifted  canula  (Fig.  24(3)  to  control  hemorrhage.     The 


518    genito-Xjrinary  organs  of  the  male. 

latter  can  be  readily  made  bypassing  the  beak  of  a  female 
silver  catheter  through  the  center  of  a  piece  of  iodoform 


Fig.  238. 


Fig.  239.     Fig.  240.      Fig.  241.      Fig.  24-2. 


Gorget,  Scoop. 


Lithotomy  Btaff. 


gauze  eight   inches  square,  and   tying  the  two  firmly  to- 
gether, as  Bhown   in   the  figure.     It    is  then  introduced 


LITHOTOMY. 


519 


into  the  wound,  the  beak  of  the  catheter  in  the  bladder, 
the  pouch  tightly  packed  afterward  with  pledgets  of  gauze, 
and  the  whole  kept  in  place  by  a  J-bandage.  Three  as- 
sistants, at  least,  are  required  :  one  to  administer  the 
anaesthetic,  the  others  to  hold  the  knees  and  the  staff. 

Operation. — The  patient,  having  had  his  bowels  emptied 
by  an  enema,  is  placed  upon  his  back,  his  ankles  bound 
last  to  his  wrists,  the  staff  introduced,  and  the  stone 
touched  with  it.  It  is  not  necessary  that  the  beak  of  the 
staff  should  rest  upon  the  stone  during  the  operation;  on 


Fig.  24:;. 


Figs.   244,  245. 


Fio.  246. 


the  contrary,  it  is  better  to  hook  the  staff  up  under  the 
symphysis  bo  as  to  keep  it  steady,  with  its  curve  bellied 
out  in  the  median  line  of  the  perineum,  and  the  integu- 
ment stretched  over  it  by  drawing  the  scrotum  up  around 
the  staff. 


520     GENITO-XJR1NARY  ORGANS  OF  THE  MALE. 

The  operator  passes  his  index-finger  into  the  rectum, 
and  satisfies  himself  that  the  staff  enters  at  the  apex  of 
the  prostate  and  passes  centrally  through  it,  and  that  the 
rectum  is  empty.  Then  withdrawing  his  finger  he  feels 
along  the  raphe  of  the  perineum  for  the  groove  in  the 
staff,  aiding  himself,  if  necessary,  by  depressing  and  rais- 
ing the  handle  several  times. 

Having  found  the  groove  he  confides  the  staff  to  his 
chief  assistant,  enters  the  scalpel  a  little  to  the  patient's 
left  of  the  raphe,  from  one  and  one-quarter  to  one  and 
one-half  inches  in  front  of  the  anus,  and  passes  it  in  al- 
most parallel  to  the  rectum  so  as  to  enter  the  groove 
about  half  an  inch  in  front  of  the  apex  of  the  prostate, 
guiding  it,  if  he  thinks  best,  by  keeping  his  left  index- 
finger  upon  the  prostate  in  the  rectum.  (If  the  knife 
should  be  passed  directly  in  to  the  nearest  point  on  the 
staff,  the  bulb  would  be  involved  to  an  unnecessary  ex- 
tent.) As  soon  as  the  point  of  the  knife  has  entered  the 
groove,  it  is  pushed  along  for  half  an  inch,  dividing  the 
floor  of  the  urethra  to  that  extent,  and  then  withdrawn, 
cutting  steadily  downward  and  outward  so  as  to  make  a 
cutaneous  incision  about  three  inches  long,  passing  mid- 
way between  the  anus  and  left  tuber  ischii. 

The  probe-pointed  Blizard's  knife,  guided  upon  the  left 
index-linger,  is  passed  into  the  groove,  and  the  surgeon 
takes  the  handle  of  the  staff  from  the  assistant,  depresses 
it  somewhat,  and  pushes  the  knife  along  until  its  point  is 
arrested  at  the  termination  of  the  groove  at  the  end  of  the 
staff.  Then  depressing  the  handle  of  the  knife,  and  hear- 
ing in  mind  the  shape  and  position  of  the  prostate,  he 
makes  an  incision  in  it  downward  and  outward  at  an  angle 
of  about  30°  with  the  horizon. 

The  index-finger  is  next  introduced,  the  staff  withdrawn, 

and  the  neek  <ii'  the  Madder  gently  dilated  with  the  linger, 
or,  if  the  perineum  is  deep  and  fat,  with  the  blunt  gorget 
carried  in  along    the   groove  in  the    stall".       II"  the  stone  is 

more  than  one  inch  in  diameter,  the  knife  must  be  reintro- 
duced and  the  prostate  cut   upon  its  right  side  also. 

The    forceps  are  then    introduced  as  the   linger  is  with- 


LITHOTOMY.  521 

drawn,  and  the  stone  sought  for  by  opening  and  closing 
the  blades  at  different  points  on  the  floor  of  the  bladder  ; 
or  the  small  end  of  the  scoop  may  be  introduced,  placed 
in  contact  with  the  stone,  and  the  forceps  guided  along  it. 
If  the  stone  is  seized  in  a  faulty  direction,  it  must  be 
dropped  and  caught  again,  or  straightened  with  the  fingers 
while  still  held  between  the  blades.  Extraction  should 
be  made  slowly  downward  and  outward  in  the  line  of  the 
external  incision,  and  aided  by  lateral  movements  of  the 
handles.  If  it  is  found  that  the  stone  is  too  large  to  be 
removed  without  employing  too  much  force,  it  must  be 
crushed  and  the  fragments  removed  separately.  Small 
stones  and  fragments  are  best  removed  with  the  scoop  and 
by  thorough  washing. 

In  operating  upon  children  certain  modifications  are  re- 
quired. If  the  incision  in  the  urethra  and  at  the  neck  of 
the  bladder  is  not  sufficiently  free,  it  may  happen  that,  in 
the  attempt  to  introduce  the  finger,  the  urethra  will  be  torn 
entirely  across  and  the  bladder  pushed  up  before  it. 
Again,  the  bladder  is  placed  higher  in  the  child  than  it  is 
in  the  adult,  and  therefore  the  point  of  the  knife  must  be 
more  raised  in  making  the  deep  incision,  and  care  must 
be  taken  not  to  let  it  slip  in  between  the  rectum  and 
bladder.  Mr.  Erichsen  l  says  he  has  known  this  to  occur 
in  several  instances,  and  the  forceps  to  be  passed  into  this 
space  under  the  impression  that  it  was  the  bladder. 

It  has  also  happened  to  some  surgeons  to  force  the  beak 
of  the  staff  through  the  roof  of  the  urethra  into  the  space 
Ik  tween  the  bladder  and  posterior  face  of  the  pubes,  and 
to  be  so  deceived  by  its  freedom  of  motion  in  the  loose 
cellular  tissue  of  that  region  that  they  thought  it  Avas  in 
the  bladder,  and  cut  upon  it  accordingly. 

Median  Lithotomy. — The  only  instruments  required 
other  than  those  used  in  the  lateral  operation  are  a  staff, 
director,  and  knife.  The  staff  has  a  central,  broad,  deep 
groove  on  its  convexity  (Fig.  247),  the  director  has  a 
ball-point  (Fig.  248),  and  the  knife  is  straight,  stout,  and 
sharp-pointed,  with  a  cutting  edge  upon  the  back  also  for 
a  short  distance  from  the  point  (Fig.  249). 

tScienceand  Art  of  Surgery,  Vol.  II.,  p.  682,  Phila.,  1873. 


522      GENITO-URINARY  ORGANS  OF  THE  MALI:. 

The  patient  having  been  bound  in  the  lithotomy  posi- 
tion and  the  staff  introduced,  the  surgeon  places  his  left 
index-finger  in  the  rectum  against  the  apex  of  the  prostate, 
and  plunges  the  knife  with  its  edge  upward  into  the  raphe 
of  the  perineum  half  an  inch  in  front  of  the  anus  in  such 


Fie..  247, 


Fig.  248. 


Fig.  249. 


Staff  i'"i'  median  lithotoi 


Ball-pointed  director. 


Double-edged  scalpel' 


;1  direction  thai  its  point  will  enter  the  groove  of  the  stall' 
jusl  al  the  apex  of  the  prostate  The  knife  is  pushed  very 
slightly  l>ad<  along  the  groove  so  as  certainly  to  open  the 
urethra  and  nick  the  end  of  the  prostate,  then  brought  for- 


SUPRAPUBIC  CYSTOTOMY.  523 

ward,  dividing  the  membranous  portion  of  the  urethra,  and 
swept  around  the  bulb  by  raising  the  handle,  making  an 
external  incision  upward  along  the  raphe*  for  about  one 
and  a  quarter  inches.  The  director  is  next  passed  along 
the  staff  into  the  bladder,  the  two  separated  angularly  to 
make  partial  dilatation  of  the  neck,  the  staff  withdrawn, 
and  the  dilatation  completed  with  the  finger.  The  forceps 
are  then  introduced  and  the  stone  removed  as  in  lateral 
lithotomy. 


SUPRAPUBIC  CYSTOTOMY  FOR  VESICAL  CALCULUS. 

The  patient  and  the  skin  surface  arc  prepared  in  the 
usual  way  for  an  aseptic  operation,  and  after  etherization 
the  bladder  is  irrigated  clean  with  a  warm  saturated  solu- 
tion of  boric  acid.  The  viscus  is  then  distended  with  as 
much  of  this  solution  as  can  be  ejected  from  an  irrigator 
vessel  elevated  not  more  than  two  feet ;  such  a  pressure 
is  harmless,  while  the  injection  of  a  fixed  amount  of  fluid 
or  the  use  of  a  hand  syringe  may  not  be,  owing  to  the 
uncertainty  as  to  the  capacity  of  the  bladder  and  the 
condition  of  its  walls. 

The  catheter  is  then  withdrawn  from  the  urethra  and 
a  thin-walled  soft-rubber  bag  (colpeurynter),  is  placed  in 
the  rectum  above  the  sphincter  and  cautiously  distended 
by  a  Davidson  syringe,  using  not  more  than  eight  or  ten 
ounces  of  water.  This  simply  presses  the  bladder  for- 
ward and  brings  its  floor  more  within  reach,  but  it  does 
not  materially  alter  the  relation  of  the  peritoneum  to  its 
anterior  wall,  and  hence  this  use  of  the  colpeurynter  can 
generally  be  dispensed  with. 

An  incision  two  or  three  inches  long  is  then  made  from 
just  below  the  upper  border  of  the  symphysis  pubis  up- 
ward in  the  median  line  and  deepened  layer  by  layer  as 
nearly  as  possible  between  the  recti,  and  the  underlying 
fascia  is  divided. 

If  more  space  is  required  the  recti  and  fascia  can  be 
cut  transversely  to  a  greater  or  less  extent  close  to  the 
pubes.     The  peritoneum  does  not  descend  on  the  anterior 


524      GENITO-UMNARY  ORGANS  OF  THE  MALE. 

wall  of  the  bladder  below  the  urachus,  which  can  some- 
times be  felt  as  a  cord  attached  to  a  knot  on  the  fundus, 
and  by  carrying  the  dissection  directly  inward  through 
the  prevesical  fat  with  blunt-pointed  scissors,  aided  by 
the  finger,  and  avoiding  unnecessary  laceration  of  the 
tissues,  the  bladder  is  exposed ;  after  pushing  upward  the 
fatty  and  cellular  tissue  which  carries  the  peritoneum  with 
it,  a  tenaculum  is  inserted  in  the  highest-exposed  part  of 
the  bladder  wall  and  a  knife  is  plunged  into  it  just  below 
the  tenaculum,  opening  the  bladder  mesially  downward 
for  about  an  inch.  Each  side  of  the  incision  is  grasped 
by  catch  forceps  which  serve  to  hold  the  opening  in  the 
abdominal  wound. 

The  peritoneum  may  descend  as  a  fold  nn usually  low  in 
front,  and  this  must  be  recognized  in  the  dissection,  which 
in  such  cases  should  be  first  downward  and  inward  behind 
the  pubes  and  then  up  over  the  anterior  surface  of  the  blad- 
der, pushing  the  unopened  peritoneum  out  of  the  way  ;  the 
numerous  veins  which  are  encountered  are  drawn  aside  or 
ligated  as  they  are  divided,  but  it  is  unnecessary  to  waste 
time  searching  for  bleeding  points,  as  the  hemorrhage 
generally  ceases  spontaneously  on  opening  the  bladder. 

The  interior  of  the  latter  is  then  explored  by  sight  and 
touch,  and  any  loose  stones  are  picked  up  with  instruments, 
preceded,  if  necessary,  by  crushing;  the  mouth  of  a  di- 
verticulum containing  a  stone  may  have  to  be  gently  di- 
lated, but  never  cut,  and  the  stone  scooped  or  irrigated 
out,  or  first  nibbled  into  fragments  by  forceps  ;  project- 
ing portions  of  the  prostate  preventing  the  free  escape  of 
urine  are  excised  as  described  under  prostatectomy,  and 
finally  the  interim-  of  the  bladder  is  washed  free  from  all 
clots  and  dibris  with  warm  boric  solution. 

A-  a  general  rule,  a  wound  in  a  comparatively  normal 
bladder  wall  should  be  closed  with  sutures,  but  if  there  is 
much  pus  or  inflammatory  change  present  it  is  better  to 
Leave  the  wound  open. 

To  insert  the  sutures  a  blunt  tenaculum  IS  placed  in 
each  extremity  of  the  incision  in  the  bladder,  lifting  up 
and  steadying  it.       Interrupted  sutures  of  chroiiiicized  cat- 


SUPBAPUBK '  CYSTOTOM  Y. 


525 


gut  arc  then  inserted  by  a  fine,  curved  needle  at  intervals 
of  a  quarter  of  an  inch  close  to  the  edges  of  the  wound 
and  passing  through  the  cut  surface  without  entering  the 
thin  mucous  membrane  ;  over  and  between  these  is  placed 
a  row  of  chromicized  catgut  Lembert  sutures  extending  a 
short  distance  beyond  the  extremities  of  the  incision,  and 
after  all  the  sutures  have  been  tied  the  bladder  is  filled 
with  boric  solution  to  test  their  efficacy. 

Fig.  250. 


Muscular  coat 
Mucous  coat 
Method  of  suturing  a  wound  of  the  bladder. 

Weak  points  are  then  reinforced  by  additional  Lembert 
sutures.  An  iodoform-gauze  packing  is  placed  in  contact 
with  this  suture  line,  and  if  considered  necessary  one  or 
more  rubber  drainage  tubes  can  be  added  ;  the  abdominal 
wound  is  then  partially  closed  with  silk  sutures,  a  couple 
of  which  are  left  untied  till  the  drainage  is  removed  sev- 
eral days  later  if  all  goes  well,  when  the  wound  can  be 
closed  tight. 

An  antiseptic  dressing  is  applied  and  a  catheter  for  con- 
tinuous drainage  is  fastened  in  the  bladder  through  a  peri- 
neal puncture  as  described  under  external  urethrotomy  by 
McBurney's  gorget.  Some  surgeons  prefer  to  leave  the 
urine  to  escape  by  its  natural  path,  or  tie  a  catheter  in  the 
urethra  for  a  day  or  two. 

In  about  half  of  the  properly  selected  cases  primary 
union  of  the  bladder  may  be  expected. 

If  the  bladder  wound  must  be  left  open  its  lips  may  be 
temporarily  fastened  in  the  margins  of  the  abdominal  inci- 
sion, and  the  latter  is   partially  closed  above  and  below, 


526      GENITO-UBINABY  ORGANS  OF  THE  MALE. 

while  a  light  iodoform-gauze  packing  is  placed  in  any 
pockets  which  may  have  become  infected  around  the  open- 
ing in  the  bladder.  A  rubber  drainage  tube  with  lateral 
perforations  near  its  lower  extremity  is  then  inserted  into 
the  deepest  part  of  the  bladder,  and  the  other  extremity 
passing  out  of  the  wound  is  connected  with  a  tube  which 
terminates  below  the  surface  of  a  1:60  carbolic  solution 
contained  in  a  bottle  under  the  bed. 

To  favor  the  action  of  the  tube,  it  is  surrounded  at  its 
exit  from  the  bladder  by  a  tight  iodoform-gauze  packing, 
bat  still  a  large  proportion  of  the  urine  will  inevitably 
escape  into  the  dressings ;  no  other  drainage  is  required. 
The  tube  is  prevented  from  slipping  out  by  a  silk  suture 
passed  through  it  and  the  skin. 

Transverse  Incision. — If  the  bladder  is  very  contracted 
and  it  is  deemed  unsafe  to  use  the  rectal  bag,  so  that  the 
bladder  must  be  sought  at  a  greater  depth  than  usual,  a 
transverse  incision  dividing  both  recti  gives  easier  access  to 
it.  This  incision,  slightly  convex  downward,  is  made  close 
along  the  upper  margin  of  the  symphysis  and  extended 
about  two  inches  to  either  side  of  the  median  line.  After 
it  has  been  carried  through  the  recti  and  fascia  into  the 
prevesical  space  the  subsequent  operations  are  as  above 
described. 

Langenbuch  divides  the  suspensory  ligament  of  the 
penis  and  exposes  the  lower  part  of  the  bladder  below  the 
I  ml  xs  by  an  inverted  1-incision.  The  vertical  limb  lies 
over  the  symphysis  and  the  oblique  ones  follow  the  edges 
of  the  descending  rami  of  the  pubes. 

PROSTATECTOMY. 

Suprapubic. — The  rectal  bag  is  inserted  and  Idled,  and 
the  bladder  is  opened  and  washed  out,  as  already  described, 
and  if  the  enlargement  is  pedunculated  i(  is  simply  sur- 
rounded with  or  withoui  transfixion  by  a  silk  ligature,  the 
ends  of  which  are  left  long  and  brought  out  of  the  abdom- 
inal wound,  while  the  mass  is  left  to  slough  away  or  is 
immediately  excised  w  ith  scissors. 


PROSTATECTOMY.  527 

When  the  projection  cannot  be  ligated  it  may  be  re- 
moved with  the  ecraseur  or  galvano-cautery.    The  uniform 

"collar"  projection  of  the  prostate  is  excised  by  dividing 
its  margins  transversely  above  and  below,  and  shelling  out 
each  semi-circular  half  with  the  fingers  after  incising  the 
mucous  membrane  on  the  summit  of  the  ridge. 

Keves  strongly  recommends  the  use  of  the  rongeur  for- 
ceps to  cut  away  the  hypertrophied  posterior  lip  of  the 
orifice.  In  no  case  should  any  portion  of  the  projecting 
valve  be  left  behind,  and  finally  the  patency  of  the  ureth- 
ral canal  is  ascertained  by  the  passage  of  the  finger  as  far 
as  the  first  joint. 

Hemorrhage  is  controlled  by  packing  with  iodoform 
gauze  or  by  the  cautery.  At  the  close  of  the  operation  the 
extremities  of  the  abdominal  wound  are  drawn  together 
around  the  opening  in  the  bladder,  which,  if  possible,  is 
sutured  to  the  margins  of  the  wound,  while  all  spaces 
which  are  liable  to  infection  are  packed  with  iodoform 
gauze,  and  a  siphon  drain  is  placed  in  the  bladder. 

Perineal  Prostatectomy. — The  urethra  is  opened  in  the 
membranous  portion  for  about  an  inch  or  an  inch  and  a- 
half  by  an  external  urethrotomy,  and  after  inserting  a 
gorget  the  finger  is  passed  to  the  bladder  by  gradual  dila- 
tation of  the  urethra  and  the  projection  located  and  ex- 
plored. The  finger  must  then  be  withdrawn  to  make  room 
for  the  ecraseur,  galvano-cautery,  or  one  of  Thompson's 
forceps  by  which  the  growth  is  snared  or  torn  from  its  at- 
tachments. 

Hemorrhage  is  checked  by  irrigation  with  very  hot  or 
very  cold  water,  or  by  packing,  and  the  subsequent  treat- 
ment is  the  same  as  for  external  urethrotomy.  This  method 
is  seldom  used  because  of  its  limited  applicability  and  the 
difficulty  of  manipulation. 

For  hypertrophy  of  the  lateral  lobes  of  the  prostate 
Dittcl !  proposes  an  incision  from  the  coccyx  to  the  median 
line  of  the  perineum,  passing  around  one  side  of  the 
sphincter.  The  dissection  is  carried  down  to  the  prostate 
in  front  and  at  the  sides  of  the  rectum,  which  is  rendered 
1  Wien.  med.  Woch.,  1890,  Nos.  18  19, 


528      GENTTO-URINARY  ORGANS  OF  THE  MALE. 

prominent  by  packing-,  and  a  cuneiform  section  is  removed 
from  the  enlarged  portions  of  the  gland  like  a  tumor,  -with- 
out opening  the  urethra.  The  resulting  wound  is  then 
drawn  together  with  catgut  and  a  strand  of  iodoform  gauze 
inserted  for  drainage.  Or  a  curved  incision  circumscrib- 
ing the  anterior  half  of  the  anus  may  be  made  ;  the  flap  is 
turned  down,  and  the  prostate  reached  by  working  along 
the  front  of  the  rectum. 

Combined  Suprapubic  and  Perineal  Method. — Belfield  ' 
and  Alexander 2  first  open  the  bladder  above  the  pubes  and 
then  reach  the  prostate  by  a  median  incision  in  the  perin- 
eum opening  the  membranous  urethra.  The  capsule  of 
the  prostate  is  opened  at  its  apex  and  stripped  off  back 
to  the  base,  and  one  lobe  separated  from  above  downward 
and  removed,  while  the  prostate  is  pressed  into  the  perin- 
eal wound  by  the  finger  of  an  assistant  within  the  bladder. 
Nicoll3  carries  the  perineal  incision  backward  past  one  or 
both  sides  of  the  anus. 

Enlarged  Prostate  Treated  by  Castration. — Cases  of  hy- 
pertrophied  prostate  complicated  by  retention  and  cystitis 
have  been  successfully  treated  by  castration.  The  pros- 
tate atrophies  within  a  year  or  less  and  the  obstruction  to 
the  escape  of  urine  thus  disappears.  The  operation  is 
simple  and  less  dangerous  than  prostatectomy,  and  the 
results  have  been  satisfactory  in  the  soft  forms. 


TUMORS  OF  THE  BLADDER. 

The  bladder  is  rendered  as  aseptic  as  possible  by  wash- 
ing and  is  then  explored  by  a  suprapubic  cystotomy.  When 
malignant  disease  is  found  lying  near  the  fundus  (which 
is  its  rarest  location),  and  of  limited  extent,  a  sponge  is 
placed  in  the  interior  of  the  bladder  to  soak  up  all  the 
urine,  and  if  the  peritoneal  cavity  must  he  opened  to  effect 

a  thorough  removal  of  the  disease,  it  is  protected  by  a 
sponge  packing  and  the  bladder  wall  divided  with  scissors, 

1  \m.  . I. ,mii.  Med.  s,i.,  Nov.,  1890. 
*N.  Y.  Med  Record,  Dec.  12,  1896. 
;  Lancet,  April  1  I.  1894. 


TUMOBS  OF  THE  BLADDER.  529 

including  the  peritoneum,  if  necessary,  well   outside  the 
limits  of  the  growth. 

The  peritoneal  part  of  the  wound  in  the  bladder  is  then 
elosed  by  Lembert  silk  sutures,  which  must  not  enter  the 
mucous  membrane,  the  protective  packing  removed,  after 
thorough  cleansing  of  the  abdominal  cavity,  and  the  peri- 
toneum above  the  bladder  drawn  together  with  catgut. 
The  rest  of  the  bladder  wound  is  treated  as  in  simple 
suprapubic  cystotomy. 

If  the  cancer  occupies  the  sides  or  base  of  the  bladder 
most  surgeons,  in  this  country  at  any  rate,  advise  against 
an  attempt  at  radical  removal  and  arc  content  with  curet- 
ting to  ameliorate  symptoms. 

A  few  successful  cases  are  reported  in  which  the  disease 
has  been  removed  with  the  surrounding  mucous  mem- 
brane, but  leaving  the  muscular  coat  from  which  the 
growth  is  sometimes  found  separated  by  a  layer  of  fat. 

Helferich  l  resects  the  pubes  through  a  transverse  in- 
cision above  the  symphysis  and  so  gains  access  to  the  an- 
terior surface  of  the  bladder. 

Niehans  2  performs  a  very  similar  operation  which  he 
calls  an  osteoplastic  resection  of  the  pubes. 

ZuckerkandF  exposes  the  base  and  adjacent  posterior 
surface  of  the  bladder  by  a  curved  transverse  incision 
through  the  perineum  in  front  of  the  anus  and  rectum, 
which  are  turned  down  and  drawn  back.  (See  removal 
of  seminal  vesicles.) 

Bramann  '  chisels  out  a  small  piece  of  the  symphysis,  in- 
cluding the  portion  connected  with  the  recti,  by  a  T-shaped 
incision,  the  horizontal  limb  lying  above  the  pubes  be- 
tween the  cords  and  the  vertical  over  the  symphysis ;  at 
the  conclusion  of  the  operation  the  bone  is  sutured  back 
in  position  and  the  patient  fixed  in  a  half-sitting  position 
with  the  legs  flexed. 

For  total  extirpation  of  bladder  or  its  mucous  mem- 
brane, see  American  Journal  of  the  Medical  Sciences,  Jan- 

1  Arcliiv  f.  klin.  (hir.,  1888,  p.  625. 
*Centralb.  f.  Chir.,  1888,  p.  -",21. 
8Wien.  med.  Presse,  1889,  Nos.  21-22, 
•Centralb.  f.  Chir.,  1893,  No.  17. 
34 


530      GENITO-UBINABY  ORGANS  OF  THE  MALE. 

iiai-v,  1891,  p.   101,  and    Wien.  med.   Presse,  1889,  Nos. 
27-28. 

Benign  growths  which  arc  more  or  less  pedunculated 
are  treated  in  the  manner  described  for  suprapubic  pros- 
tatectomy and  their  bases  scraped  or  cauterized  or  touched 
with  a  ten  per  cent,  solution  of  chloride  of  zinc. 

If  the  tumor  has  a  small  enough  pedicle,  the  latter  can 
be  grasped  by  a  pair  of  forceps  close  to  the  bladder  wall, 
and  the  tumor  twisted  off  on  the  distal  side  of  the  forceps, 
which  are  held  immovable  ;  but  unless  all  portions  of  the 
growth  are  removed  it  is  liable  to  recur.  Benign  tumors 
can  occasionally  be  torn  from  their  attachments  by  forceps 
introduced  through  an  external  urethrotomy  wound,  but 
care  must  be  taken  not  to  force  the  bladder  wall  into  the 
grasp  of  the  instrument  by  pressure  on  the  hypogastrium. 
There  is  less  danger  of  rupturing  the  bladder  than  might 
be  supposed,  owing  to  the  usual  hypertrophy  of  the  mus- 
cular coat  underlying  the  tumor. 

REMOVAL   OF   THE   SEMINAL   VESICLES.1 

ZuCKERKANDl/s  INCISION.2 — The  patient  is  placed  in 
the  lithotomy  position  with  a  sound  in  the  urethra  to  mark 
it-  position  and  the  bladder  partially  filled  with  a  satu- 
rated solution  of  boric  acid.  A  slightly  curved  incision 
with  its  concavity  towards  the  anus  is  made  transversely 
across  the  perineum,  having  its  center  about  one  inch  and 
a-half  in  front  of  the  anus.  From  each  extremity  of  this 
a  straight  diverging  incision  about  an  inch  and  a-half  long 
passes  back  on  either  side  of  the  amis  to  end  near  the 
tuber  ischii.  After  division  of  the  skin  and  subcutaneous 
tissue  a  linger  is  placed  in  the  rectum  and  the  perineal 
septum  cut  through,  avoiding  the  anterior  rectal  wall. 

The  dissection  is  deepened  till  above  the  sphincter  ani, 

which  is  then  turned  down  with  the  rectum  while  the  bulb 
of  the  urethra  is  pushed  forward,  and  the  pubic  portion 
of  the  levator  ani  i>  divided  on  each  side  of  the  prostate. 

'See also  DTlmann:  Centralb.  f.  Chir.,  Feb.  22,  1890. 
2  Wien.  med.  I'-    e    L889,  p,  B56. 


BEMO  VA  L   OF  SEMIS.  1 1    \  rESI(  'L  ES. 


531 


Free  hemorrhage  may  be  expected  from  the  hemorrhoidal 

and  prostatic  plexus  of  veins,  but  it  is  easily  controlled 
by  pressure  or  clamps.  Then,  by  tearing  through  tin- 
loose  connective  tissue,  the  rectum  is  easily  separated  a  little 
more  fully  from  the  bladder,  the  base  of  which  can  be 


Fig.  261. 


Zackerkandl's  incision  for  removal  of  the  seminal  vesicles.    P.  Prostate.    IV.  Vas 

deferens.     Vs.  Vesieula  seminalis.    J/.  Rectum. 


made  more  prominent  by  manipulating  the  sound,  and  the 
prostate,  vasa  deferentia,  and  seminal  vesicles  are  brought 
into  clear  view. 

It  only  remains  to  dissect  off  one  or  both  vesicles  and 
to  ligate  the  corresponding  vas  deferens  with  catgut. 

The  wound  is  closed  and  dressed  antiseptically  with  a 
rubber  drainage  tube  and  light  iodoforin-gauze  packing  in 
its  most  dependent  angles.  The  seminal  vesicles  can  also 
be  reached  by  an  incision  beside  the  sacrum  and  coccyx  as 
in  Kraske's  operation  for  cancer  of  the  rectum  (Bolton). 

The  vas  deferens,  cord,  and  testicle  can  be  extirpated 
at  the  same  time  by  an  incision  starting  over  the  internal 
abdominal  ring  and  passing  down  through   the  inguinal 


532      GENITO-URINARY  ORGANS  OF  THE  MALE. 

canal  into  the  scrotum.  This  incision  is  deepened  layer 
I  iy  layer  above  the  pubes,  the  peritoneum  recognized  and 
pushed  up,  and  then  by  working  with  the  fingers  from 
above  and  below  (through  Zuckerkandl's  incision)  thevas 
can  be  separated  from  the  bladder  and  pulled  out  through 
the  opening  in  the  abdominal  wall. 


CHA  PTER     VIII. 

OPERATIONS  UPON  THE  GENITO-URINARY  ORGANS 
OF  THE  FEMALE. 

CATHETERIZATION. 

The  surgeon,  standing  on  the  right  side  of  the  patient 
and  holding-  the  catheter  in  his  right  hand,  with  its  convex- 
ity lying  on  the  palmar  surface  of  the  index-finger  and  its 
beak  not  quite  reaching  to  the  end  of  the  distal  phalanx 
(  Fig.  252),  separates  the  nymphse  with  the  thumb  and 
middle  finger  of  his  left  hand,  introduces  his  right  index- 
finger  at  the  fourchette  and  brings  it  forward,  recognizing 
the  entrance  to  the  vagina  and  its  anterior  border,  and 
stopping  when  he  feels  the  pouting  orifice  of  the  urethra. 
Then  keeping  the  pulp  of  the  finger  below  and  in  contact 
with  the  orifice  he  passes  the  catheter  in. 

Fig.  252. 


Mode  of  holding  the  catheter. 

EXTERNAL  URETHROTOMY. 

The  Buttonhole  Operation  (Emmet)  (Fig.  253). — The 
patient  is  anaesthetized  and  placed  on  the  left  side,  and  the 
fourchette  retracted  with  a  small  Sims's  speculum.  A  full- 
sized  metal  sound  is  introduced  into  the  urethra,  then  the 

533 


534     GENlTO-VRtNARY  ORGANS  OF  THE  FEMALE. 

tissues  in  the  vaginal  surface  are  caught  up  with  a  tenacu- 
lum and  divided  longitudinally  midway  between  the  meatus 

Fig.  253. 


External  uretbrotom 


and  the  neck  of  the  Madder.     The  incision  may  then  be 
extended  with  scissors.     Neither  the  neck  of  the  bladder 

Fig.  254. 


Emmet's  buttonhole  scissors, 


nor  the  meal  us  should  be  divided.       If  the  incision  is  to  be 
kept  open,  the  urethral  mucous  membrane  must  be  drawn 


l.lTUnTOMY 


535 


out  through  it  and  stitched  with  catgut  to  the  edge  of  the 
divided  vaginal  surface.  The  incision  may  be  conveni- 
ently made  with   Emmet's  buttonhole  scissors  (Fig.  254). 

LITHOTOMY. 

Besides  the  suprapubic,  which  is  performed  in  the  man- 
ner already  described,  there  are  the  urethral  and  vesico- 
vaginal operations.  In  the  former  the  stone  is  removed 
through  the  urethra  after  the  calibre  of  this  canal  has  been 
increased  by  an  incision  along  its  anterior  (upper)  wall,  or 
on  one  or  both  sides,  incisions  which  do  not  extend  into 
the  vagina.  In  the  latter  the  stone  is  removed  through 
an  incision  made  in  the  vesico-vaginal  septum. 

Urethral  Lithotomy. — The  only  instruments  actually  re- 
quired are  a  director,  a  probe-pointed  knife,  and  forceps, 
but  some  surgeons  prefer  to  make  the  incision  with  a  sin- 
gle or  double  lithotome  introduced  alone  or  upon  a  direc- 
tor. Lateral  incisions  should  incline  upward  rather  than 
downward  ;  consequently,  if  the  double  lithotome  is  used, 
it-  concavity  should  be  turned  toward  the  symphysis. 
The  extraction  of  the  stone  requires  no  additional  de- 
scription. 

Vesico-vaginal  Lithotomy. — The  patient  may  be  placed 
in  the  usual  lithotomy  position,  or  upon  the  side,  or  upon 

Fig.  255. 


Sinis's  speculum. 


the  face.     A  Sims's  speculum  (Fig.  255  )  is  pressed  against 
the  posterior  wall  of  the  vagina,  and  a  grooved  catheter 


536     GENITO-UBINABY  ORGANS  OF  THE  FEMALE. 

introduced  into  the  bladder  and  confided  to  an  assistant, 
who  keeps  it  pressed  well  against  the  vesico- vaginal 
septum. 

Guiding  his  knife  upon  the  groove  the  surgeon  makes 
an  antero-posterior  incision  in  the  median  line  of  the  an- 
terior wall  of  the  vagina,  about  one  inch  in  length,  and 
not  involving  the  neck  of  the  bladder,  passes  in  his  index- 
finger,  and  then  the  forceps  upon  the  ringer  as  a  guide. 

Emmet  places  no  sutures,  but  allows  the  wound  to 
close  spontaneously,  keeping  the  bladder  clean  by  fre- 
quent washings.  Guy  on  closes  the  incision  immediately 
with  sutures. 

In  a  discussion  in  the  Societe  de  Chirurgie '  the  fact 
was  brought  out  that  lithotomy  and  lithotrity  upon  the 
female  are  more  dangerous  operations  than  they  are 
usually  said  to  be.  The  fatal  complications  are  of  two 
kinds:  peritonitis  in  patients  who  have  previously  been 
affected  by  it ;  and  pyaemia,  originating  in  inflammation 
of  the  spongio-vascular  tissue  constituting  part  of  the 
vesico-vaginal  septum.  Speaking  generally,  it  may  be 
said  that  lithotrity  -  is  more  dangerous  in  the  female  than 
lithotomy,  that  the  supra-pubic  operation  should  be  used 
for  large  calculi,  dilatation  of  the  urethra  for  small  ones, 
and,  with  crushing,  for  large  friable  ones  when  the  in- 
flammation is  not  high  and  there  has  been  no  previous 
peritonitis;  urethral  or  vesico-vaginal  lithotomy  in  other 
cases.  As  to  the  comparative  merits  of  urethral  and 
vesico-vaginal  lithotomy  opinions  are  divided  ;  the  former 
is  followed  occasionally  by  permanent  incontinence;  the 
latter  by  fistula  ;  probably,  too,  the  latter  is  somewhat 
more  dangerous  than  the  former. 

OCCLUSION,  OR  ATRESIA  VAGINA. 

When  the  occlusion  is  due  simply  to  an  imperforate 
hymen  it  may  be  relieved  by  successive  punctures  with  a 

1  Hull,  de  la  Socfcte"  de  Chirorgie,  1*77,  pp.  182  and  WO. 

:!ln  thia  remark  reference  is  made  i<>  the  old  operation  of  lithotrity. 
'I'lic  few  cases  of  litholapaxy  in  the  female  of  which  I  have  knowledge 
have  been  successful. 


PERINEORRHAPHY.  537 

small  trocar  or  aspirator,  and  when  all  the  accumulated 
menstrual  blood  has  been  thus  removed,  and  the  cavity 
well  washed  out  with  a  two  per  cent,  solution  of  carbolic 
acid,  the  hymen  may  be  excised,  or  a  large  puncture 
made,  and  kept  open  by  frequently  passing  a  sound.  It 
must  be  remembered  that  very  serious  complications,  such 
as  peritonitis  and  septic  poisoning,  may  follow  this  simple 
operation  when  there  has  been  a  large  accumulation  of 
menstrual  blood  above  the  obstruction. 

When,  on  the  other  hand,  this  occlusion  is  due  to  in- 
complete development  of  the  vagina,  a  more  systematic 
operation  is  required.  The  surgeon  first  assures  himself 
by  digital  examination  through  the  rectum  of  the  existence 
of  the  uterus,  then  places  the  patient  upon  her  back  with 
her  thighs  flexed  and  abducted,  and  introduces  a  sound 
into  the  bladder  and  confides  it  to  an  assistant.  He  next 
passes  his  left  index-finger  into  the  rectum,  and  makes  a 
transverse  incision  across  the  center  of  the  obliteration, 
and  carries  it  in  the  direction  of  the  uterus  by  successive 
short  cuts  with  the  knife  or  by  tearing  with  a  director  or 
his  fingers,  guiding  his  course  by  the  sound  in  the  bladder 
and  the  finger  in  the  rectum.  As  soon  as  fluctuation  can 
be  felt  in  front  of  the  uterus  he  punctures  with  a  trocar 
and  enlarges  the  puncture  with  a  probe-pointed  bistoury. 

PERINEORRHAPHY. 

Dr.  Emmet l  has  shown  that  the  lesion  previously  known 
as  "  partial  rupture  of  the  perineum,"  and  supposed  to  be 
a  laceration  along  the  posterior  median  line  of  the  tissues 
at  the  lower  part  of  the  vagina  and  perineum,  is  actually 
a  transverse  rent  at  or  within  the  ostium  vagina?,  which, 
by  the  dropping  and  eversion  of  the  lower  lip  of  the 
wound,  is  made  to  present  the  appearance  of  a  longitu- 
dinal one.  He  also  recognized  and  described  a  variety  of 
this  lesion  in  which  the  laceration  is  submucous,  in  which 
the  muscular  and  fascial  diaphragm,  constituted  in  part 
by  the  sphincters  and  closing  the  outlet  of  the  pelvis,  is 

1  Principles  and  Practice  of  Gynecology,  188-t,  p.  364. 


538     QENIT0-XJR1NARY  ORGANS  OF  THE  FEMALE. 

turn  away  from  the  supporting  fascia1  and  muscles  which 
run  upward  to  attach  its  center  to  the  inner  side  of  the 
bony  pelvis,  and,  having  thus  lost  its  support,  allows  the 
posterior  part  of  the  vulva  to  be  everted,  with  production  of 
a  rectocele  by  protrusion  of  the  rectum  through  the  (sub- 
cutaneous) gap.  To  this  latter  condition  he  gives  the 
name  prolapse  of  flic  posterior  wall  of  the  vagina.  The 
two  conditions,  the  subcutaneous  and  the  complete  rents, 
arc  essentially  the  same,  and  require  for  their  relief  nearly 
the  same  denudation  of  the  surface.  The  aim  of  the 
operator  in  either  case  is  to  lift  up  the  depressed  everted 
lower  lip,  unite  its  edge  to  that  of  the  mucous  membrane 
of  the  vagina  at  the  crest  of  the  rectocele,  and  thus  cover 
in  the  latter  and  renew  its  anterior  support. 

Laceration  of  the  vulvar  orifice  in  the  posterior  median 
line  may  occur  without  coexistence  of  the  above-described 
lesion,  beginning  at  the  fourchette  and  extending  back- 
ward, but  such  laceration  is  unimportant  because  it  in- 
volves only  parts  that  lie  outside  the  real  support  of  the 
viscera. 

A  third  form  is  the  important  one  in  which  laceration 
of  the  sphincter  ani  in  the  median  line  takes  place.  In 
non-instrumental  delivery  this  begins  as  a  longitudinal 
slit  in  the  recto-vaginal  septum  and  extends  from  within 
outward  and  forward.  When  caused  by  the  forceps  it 
begins  at  the  fourchette  and  extends  backward.  To  this 
form  Dr.  Emmet  limits  the  term  ruptwre  of  the  pervnewm. 

Accepting  this  classification,  I  shall  describe  the  oper- 
ation for,  1st,  prolapse  of  the  posterior  wall  of  the  vagina 
— two  varieties,  with  and  without  laceration  of  the  mucous 
membrane  of  the  vagina;  and,  2d,  rupture  of  the  peri- 
neum (and  the  sphincter  ani). 

Prolapse  of  the  Posterior  Watt  of  the  Vagina.  (1st 
variety,  without  surface  laceration.)  Operation. — Thighs 
flexed  on  abdomen  and  supported  under  the  arm  of  an 
assistant  on  each  side,  who  also  draw  aside  the  labia  and 
hold  the  tenacula  during  the  act  of  denudation.  The 
operator  seizes  with  a  tenaculum  the  muCOUS  membrane 
of  the  vagina  a1  the  cresl  of  the  rectocele   in    the   median 


PERINEORRHAPHY 


:>:;•.! 


line  at  a  point  which  can  be  drawn  down  to  the  urethral 
orifice  by  gentle  traction,  and  having  thus  drawn  it  down, 
lias  it  held  in  place  by  the  assistant.  Then,  with  two 
other  tenacula,  he  hooks  up  the  lowest  caruncle  or  vestige 
of  the  hymen,  on  each  side,  and  draws  them  upward  and 
outward  to  the  first  tenaculum.  This  movement  creates 
an  inverted,  crescentic,  transverse  fold  within  the  vagina 
just  below  the  first  tenaculum,  its  horns  shading  gradually 
into  the  sulcus  on  each  side,  and  a  shallow  longitudinal 
fold  in  the  median  line  between  the  last  two  tenacula. 
The  opposed  surfaces  of  these  folds  eonstitute  the  area  to 
be  denuded. 

Dropping  one  lateral  tenaculum,  he  gives  the  other  to 
an  assistant  who  draws  it  gently  outward  to  define  by  this 
traction  the  limits  of  the  denudation  on  that  side,  and  then 
the  surgeon  denudes  by  catching  up  the  mucous  membrane 
with  a  hook  or  pronged  forceps  and  removing  it  with 
scissors  in  successive  strips.  The  process  is  then  re- 
peated on  the  opposite  side.  Care  must  be  taken  not  to 
denude  too  high  on  the  posterior  wall. 

Sutures  are  then  passed  to  unite  the  parts  in  the  posi- 
tions given  them  by  the  first  approximation  of  the  three 

Fig.  256. 


Diagram  showing  the  line  of  union  and  direction  of  the  sutures. 


tenacula,  producing  the  line  of  union  indicated  in  Fig. 
256.  The  sutures  of  the  crescentic  part  should  be  of  sil- 
ver wire ;  those  of  the  central  line  may  be  of  silver,  silk, 
or  catgut.     A  final  silver  suture  should  be  passed  through 


4 


540     GENITO-URINAMY  ORGANS  OF  THE  FEMALE. 


the  labium  uear  the  caruncle  on  one  side,  across  to  the 
posterior  wall  of  the  vagina,  under  its  mucous  membrane 
for  nearly  an  inch  just  above  the 
edge  of  the  denudation,  and  then 
through  the  other  labium  at  a  point 
opposite  to  that  at  which  it  began. 
In  passing  the  sutures  a  thick, 
straight  sewing-needle  armed  with 
silk  should  be  used,  and  the  tissue- 
to  be  traversed  by  it  should  be 
pressed  forward  by  the  finger  in  the 
rectum.  The  sutures  should  not  be 
buried  throughout  their  course,  but 
should  cross  the  fold  midway  be- 
tween its  free  edge  and  its  bottom. 
The  silver  wire  is  drawn  through  in 
the  loop  of  the  silk.  The  appear- 
ance, when  the  operation  is  com- 
pleted, is  shown  in  Fig.  '2o~,  the 
crescentric  part  being  hidden  within 
the  vagina. 
2d  Variety.  Prolapse  with  Surface  Lacera- 
tion.— The  position  of  the  patient  is  the  same  as  in  the 
preceding  form,  and  the  area  of  denudation  is  determined 


Appearance  ;it  completion 
of  operation. 


Diagram  showing  area  ol  denudation.    The  parts  bearing  corresponding  figures 
are  broughl  into  apposition  by  the  sutures. 


in  like  manner  ;   speaking  generally,  it  must  extend  down- 
Ward  to  the  line  of  junction  between  the  skin  and  thecica- 


PERINEORRHAPHY. 


541 


tricial  mucous  membrane.  Its  shape,  when  spread  out,  is 
that  of  a  trefoil  (Fig.  258).  The  sutures  are  passed  in 
order  from  below  upward,  and  none  tightened  till  all  are  in 
place.  The  lower  cues  are  buried  throughout  their  course  ; 
the  upper  ones  are  partly  exposed  on  each  side,  as  shown 
in    Fig.  *2oi».     The  suture  marked  J)  includes  about  an 

Fig.  259. 


Emmet's  operation  for  diminishing  the  vaginal  outlet  by  external  sutures. 

inch  of  the  recto-vaginal  septum  ;  the  uppermost  suture  C 
passes  through  the  mucous  membrane  of  the  septum  above 
the  denudation,  and  when  tightened  draws  it  down  like  a 
hood  to  protect  the  approximated  edges,  and  also  sustains 
all  the  traction  while  the  opposed  denuded  surfaces  are 
uniting. 

Dr.  Emmet  leaves  the  sutures  in   place  for  about  three 
weeks. 

PERINEORRHAPHY. 

Method  of  Hegar  or  Simon-Hegar.     INCOMPLETE  RUP- 
TURE.— This    is    based  on    the    principle  that    the    rent 


J 


542     GENITO-URINARY  ORGANS  OF  THE  FEMALE. 

when  spread  out  has  the  form  of  a  triangle  with  its  apex 
in  the  posterior  vaginal  wall.  (Fig.  2(50.)  After  every 
antiseptic  precaution,  bullet  forceps  arc  hooked  in  the 
three  following- points  :  in  the  crest  of  the  rectocele  in  the 
posterior  vaginal  wall,  and  in  the  opposite  lowest  carun- 
cles, which  lie  on  the  inner  surface  of  each  labium  raajus. 


Fig.  260. 


Mill     ..  ■  ■■  ■ 
[ncomplete  rupture  of  the  perineum.  Peri rrhaphy  by  Simon's  method,  (Pozzi.) 

The  labia  are  held  apart  and  traction  is  made  on  the  for- 
ceps, thus  putting  the  tissues  between  them  on  the  stretch, 
while  a  narrow  strip  of  mucous  membrane  is  removed  on 
the  lines  made  straight  by  traction,  which  join  the  crest 
of  the  rectocele  with  the  two  caruncles  in  the  grasp  of  the 
forceps.  'I'll''  space  between  these  limits  is  rapidly  de- 
nuded, and    the  denudation    is  continued  on    the    posterior 

vaginal  wall  and  adjacent  skin  as  far  as  the  cicatricial  tis- 
sue extends,  so  that  the  raw  siy^qe,  w,ljen  flattened  oul  has 


PERINEORRHAPHY 


543 


the  form  of  a  triangle  with  its  apex  in  the  rectocele,  and  its 
base,  which  is  slightly  convex  toward  the  anus,  between 
the  two  lower  forceps  on  the  inner  surfaces  of  the  labia 
majora. 

Starting  at  the  apex  (Fig.  -<>0),  at  intervals  of  about 
three-eighths  of  an  inch,  sutures  of  silver  wire  or  silk- 
worm-gut  are  passed  on  a  well-curved  needle,  so  as  to  be 
just  buried  under  the  denuded  surface,  emerging  about  a 
quarter  of  an  inch  from  its  edge. 

At  least  two  of  these  sutures  should  pass  deeply  enough 
in  the  upper  lateral  portions  of  the  raw  area  to  grasp  some 
of  the  fibers  of  the  levator  ani  muscle. 

Martin's  continuous  circular  suture  applied  in  tiers  is 
considered  better  by  many  surgeons  than  the  interrupted 
suture.  Catgut  is  used,  threaded  on  a  sharply  curved 
needle. 

Laceration  of  the  Perineum,  including  the  Sphincter  Ani. 
— If  the  anterior  wall  of  the  rectum  is  ruptured  for  more 
than  one  or  one  and  a-half  inches  above  the  upper  margin 


Fig.  261. 


?phincter. 


Ruptured  sphincter,  and  suture. 


of  the  sphincter,  it  may  be  better  to  close  it  by  a  pre- 
liminary operation,  leaving  the  restoration  of  the  perineum 
for  a  subsequent  one.  Dr.  T.  Addis  Emmet  was  the  first 
to  show  why  it  is  not  sufficient  simply  to  close  the  gap  be- 
tween the  vagina  and  rectum,  and  to  demonstrate  the  need 
of  bringing  the  ends  of  the  severed  sphincter  into  close 


544     GENITO-URINARY  ORGANS  OF  THE  FEMALE. 

contact  with  each  other,  and  with  the  end  of  the  recto- 
vaginal septum. 

Let  Fig.  261  represent  the  perfect  sphincter,  and  Fig. 
-<> :2  the  sphincter  ruptured  and  spread  out  with  the  points 

of  entrance  and  exit  of  needle  AA,  the  dotted  line  show- 
ing the  course  of  the  suture,  including  the  end  of  the 
recto-vaginal  wall  C.  As  the  suture  is  twisted,  the  three 
points  are  brought  nearer  together,  as  in  Fig.  263,  until 
they  finally  unite,  as  in  Fig.  264.     If  the  first  needle  is 

Fig.  2(53.  Fig.  2(34. 


Suture  partly  drawn.  Suture  fully  drawn. 

passed  in  and  ont  at  BB,  complete  union  of  the  ends  of 
the  muscle  will  not  be  obtained,  and  loss  of  function  will 
persist.  The  first  suture  is  the  important  one,  and  must 
bring  the  torn  ends  of  the  muscle  into  contact  with  each 
other  and  with  the  end  of  the  septum. 

In  freshening  the  parts  before  passing  the  needles  the 
two  lateral  triangles,  forming  the  ruptured  surface  of  the 
body  of  the  perineum,  are  denuded,  and  the  line  of  denu- 
dation is  prolonged  backward  along  the  edge  of  the  recto- 
vaginal septum.  This  denudation  must  extend  along  the 
edge  of*  the  mucous  membrane  of  the  rectum,  but  not  in- 
clude it.  Fig.  265  is  a  schematic  representation  of  the 
end  of  the  ruptured  bowel,  the  points  of  entrance  and 
emergence  of  the  needle,  and  the  course  of  the  first  suture. 

The  rule  for  passing  the  first  suture,  then,  is  to  enter 
the  needle  as  low  down  as  the  lower  edge  of  the  anus,  pass 

li  thence  upward  through  the  recto-vaginal  septum,  com- 
pletely encircling  the  rent,  and  bring  it  out  alongside  the 
lower  edge  of  the  anus  on  the  other  side.     Its  action,  then, 


PERINEORRHAPHY. 


545 


is  like  that  of  a  purse  string,  it  puckers  up  the  open 
parts,  controls  the  action  of  the  sphincter,  and  guards 
against  the  two  principal  sources  of  failure,  recto-vaginal 
fistula  and  non-union  of  the  sphincter  (Fig.  266). 


Fig.  265. 


Fig.  266. 


Ruptured  sphincter.     First  suture.  Complete  perineal  rupture,     First  and 

second  sutures  in  place. 

Dr.  Emmet  now  recommends  that  this  injury  should  be 
treated  as  if  it  were  "a  recto-vaginal  fistula  in  the  median 
line,  with  the  sides  easily  approximated." 

The  denudation  is  done  with  scissors,  beginning  at  the 
outlet  and  near  the  rectal  surface,  and  continuing  from 
below  upward,  so  as  to  avoid  the  flow  of  blood  over  the 
surface  yet  to  be  freshened.  .Since  the  sides  of  the  tear, 
after  retraction,  are  not  sufficiently  broad  to  give  a  good 
surface  for  union,  a  portion  of  the  adjoining  vaginal  mil- 


546     QENITO-URINABY  ORGANS  OF  THE  FEMALE. 

cons  membrane  must  be  removed,  and  the  angle  must  also 
l>e  extended  <»n  the  vaginal  surface  for  half  an  inch  or 
more  beyond   the   rectal  edge.     Then,  beginning  at  the 

angle,  several  transverse,  interrupted  silver  sutures  are 
passed  from  the  vaginal  edge  on  one  side,  under  the  de- 
nuded surface  across  the  gap,  and  under  the  opposite  de- 
nuded surface  to  the  opposite  vaginal  edge,  and  two  or 
three  additional  sutures  are  passed  by  the  old  method,  that 
is,  beginning  in  the  skin  near  the  lower  edge  of  the  anus, 
continuing  up    through  the   tissues   alongside   the   rent, 

Fig.  2f>7. 


' - ..-.: 

— * 

-  asssssss 


Half-section  through  the  pub 


through  tin'  septum,  and  down  od  the  oilier  side,  so  as 

completely  to  include  the  rent.  Fig.  267  shows  these 
different  sutures.  The  lasl  two  mentioned  are  the  'id  and 
It li  in  the  figure,  counting  from  below  upward. 

Complete  Laceration  with  Rupture  of  the  Sphincter  Ani. — 
A   Blight    modification  of  Heear's  method   is  used   in  the 


PERINEORRHAPHY 


547 


gynecological  service  of  Roosevelt  Hospital,  and  it  gives 
most  excellent  results.  Before  denuding  the  perineum  the 
rectum  is  first  sutured.  The  edges  of  the  rent  in  the  rec- 
tum are  freshened  and  the  raw  surface  is  made  a  little 
broader  below  than  above  to  thoroughly  expose  the  ex- 

Fig.  268. 


Complete  laceration  of  the  perineum.     Perineorrhaphy— Simon-Hegar  method  ; 
general  disposition  of  the  sutures.     [Pozzi.) 

tremities  of  the  sphincter  muscle.  The  denuded  areas  of 
muscular  and  mucous  tissue  arc  then  brought  into  apposi- 
tion by  interrupted  sutures  of  chromicized  catgut  or  silk- 
worm-gut passed  just  within  the  limits  of  denudation  at 
intervals  of  about  a  quarter  of  an  inch  ami  knotted  in  the 
rectum  from  above  downward  (Fig.  268).  The  ends  are 
left  long  and  protruding  from  the  anus,  and  at  the  expira- 
tion of  a  couple  of  week's  those  sutures  which  can  be  reached 


548     GENITO-UBINARY  ORGANS  OF  THE  FEMALE. 

are  removed  and  the  ends  of  the  others  are  cut  short  and 
the  sutures  are  left  to  cut  their  way  out. 

The  rest  of  the  operation  is  then  finished  by  Hegar's 
method  for  incomplete  rupture  with  Martin's  continuous 
sutures  of  catgut  placed  in  tiers  from  the  bottom  of  the 
rent  just  external  to  the  rectal  wall  up  to  the  original 
level  of  the  vaginal  mucous  membrane  (Fig.  269).     A 

Fir;.   2G9. 


.1 


li 


Complete  laceration  of  the  perineum.  Perineorrhaphy— Martin's  method,  I. 
Deep  plan  of  continuous  suture.  /:.  Passage  from  the  deep  to  the  superficial. 
(  Pozzi.) 

tension  suture  of  .-ilk  should  be  passed  through  the  skin 
of  the  perineum,  without  entering  the  rectum,  a  little  be- 
yond the  extremities  of  the  freshly  united  sphincter  and 
the  ends  of  the  suture  fastened  over  lead  buttons  or  balls, 
vvhicb  will  permit  it  to  be  loosened  if  there  is  much  sub- 
sequent swelling  or  (edema. 


VES1C0-VAQINAL  FISTULA.  549 


VESICOVAGINAL   FISTULA. 

The  patient  is  prepared  for  the  operation  by  measures 
directed  to  the  improvement  of  her  general  condition,  by 
regularly  syringing  the  vagina  with  warm  water,  and  by 
dividing  any  cicatricial  bands  that  may  have  formed  in  it. 

Position. — The  patient  is  placed  upon  the  left  side,  with 
the  thighs  flexed,  the  right  rather  more  so  than  the  left, 
the  left  arm  is  drawn  behind  her  back,  and  her  chest 
brought  Hat  down  upon  the  table.  Some  prefer  the  knee- 
elbow  position,  and  Simon  placed  the  patient  flat  upon 
her  back,  raised  the  hips,  and  flexed  the  thighs  as  far  as 
possible  upon  the  abdomen. 

Fig.  270. 


C  '  C 

a.  Vesical  surface.    //.  Vaginal  surface,    ec.  Line  of  paring. 

If  the  first  position  is  employed,  an  assistant  stands  be- 
hind the  patient,  draws  the  posterior  wall  of  the  vagina 
back  by  means  of  a  broad  Sims's  speculum  held  in  his 
right  hand,  while  with  his  left  he  raises  the  right  side  of 
the  nates. 

The  surgeon  then  pinches  up,  with  toothed  forceps  or  a 
tenaculum,  the  vaginal  edge  of  the  fistula  at  the  point 
most  difficult  of  access,  and  cuts  off  a  piece  including  in 
breadth  all  between  the  vesical  edge  of  the  fistula  and  a 
point  in  the  vagina  at  least  one-third  of  an  inch  from  the 
vaginal  edge  of  the  fistula.  The  cutting  may  be  done 
with  curved  scissors  or  a  narrow  bladed  knife.  Successive 
portions  of  the  edge  are  raised  and  removed  in  like  man- 
ner, until  the  denudation  is  complete,  the  resulting  raw 
surface  being  funnel-shaped,  with  its  narrowest  part  at 
the  edge  of  the  vesical  mucous  membrane,  the  membrane 
itself  not  being  included  in  it  (Fig.  270).  Or  the  point 
of  the  knife  may  be  entered  into  the  mucous  membrane 


J 


550     GENITO-TJRINARY  ORGANS  OF  THE  FEMALE. 


of  the  vagina  one-third  of  an  inch  from  the  edge  of  the 
fistula,  brought  out  at  the  vesical  border,  and  then  carried 


Fig.  271. 


Drawing  down  the  uterus  to  facilitate  the  paring. 

righl  and  lefil  around  the  opening  so  as  (<»  cui  off  a  com- 
plete ring  of  tissue. 

[f  the  anterior  wall  of  the  vagina   is   freely  movable, 
Simon   brings   the  fistula   into  plain  view  by  passing  a 


VESICO-VAGINAL   FlSTUl  i. 


551 


stout  ligature  through  the  cervix  of  the  uterus  and  draw- 
ing it  down  toward  the  vulva  (  Fig.  271).  He  also  pares 
the  edges  of  the  fistula  very  freely,  and  does  not  hesitate 


Fig.  272. 


cud 


a    Vesica]  surface.  6.  Vaginal  surface,  e,  Needle. 


Needle-holder. 


Passing  the  needle. 


to  include  the  mucous  membrane  of  the  bladder  in   the 
incision. 

As  soon  as  the  hemorrhage  has  ceased,  the  sutures  may  be 
passed.     The  needle,  three-quarters  of  an  inch  long,  round, 


5&2     <;  i:\rn i  URINARY  ORGANS  OF  THE  FEMALR 

slightly  curved,  and  armed  with  a  fine  double  silk  suture, 

is  fixed  in  a  needle-holder,  and  entered  at  the  angle  of  the 
wound  which  is  most  difficult  of  access,  half  an  inch  from 
the  edge  of  the  raw  surface,  and  its  point  brought  out  at 
the  edge  of  the  vesical  mucous  membrane,  but  not  includ- 
ing it  (Fig.  i>7.>:>)  and  there  fixed  with  a  blunt  hook  (Fig. 
277),  until  it  can  be  seized  and  drawn   through  with  the 


Figs.  275,  276,  27 


Fig.  278. 


L     & 


I  U 


needle  forceps.  It  is  then  entered  at  the  corresponding 
point  on  the  opposite  side,  and  brought  out  on  the  vagi- 
nal surface  half  an  inch  from  the  edge  of  the  opening 
(  Fig.  274).  The  ends  of  the  ligature  are  given  into  the 
charge  of  the  assistant  who  holds  the  speculum,  and 
another  needle  is  passed  in  the  same  manner  at  the  dis- 
tance of  one-sixth  of  an  inch  from  the  first;  and  so  on, 
until  a  sufficient  number  have  been  passed.     During  the 


VESWO   VAGINAL   FISTULA. 


►53 


passing  of  the  needles  the  sides  of  the  fistula  are  fixed  by 

the  tenaculum. 

Fig.  279. 


Simon's  method  of  placing  the  suturi 


When  the  needle  is  seized  with  forceps  and  nulled 
through,  counter-pressure  must  be  made  upon  the  tissues, 
and  this  is  best  done  by  means  of  the  split  rod  or  fork, 
represented  in  Fig.  '11 6,  its  prongs  passing  on  either  side 
of  the  needle. 


554     GEMT0-VR1NARY  ORGANS  OF  THE  FEMALE. 


After  all  the  ligatures  have  been  passed,  a  silver  wire, 
about  twelve  inches  long,  is  fastened  to  the  loop  of  the  first 
ligature  (Fig.  278,  C),  and  drawn  through  with  the  help 
of  the  fork.  The  silk  is  cut  off,  the  ends  of  the  wire  drawn 
aside  out  of  the  way,  and  the  others  passed  in  the  same 
manner. 

Simon  used  fine  silk  sutures  (two  rows  when  the  fistula 
was  large)  tied  in  the  ordinary  manner,  and  often  passing 
through  the  vesical  mucous  membrane  (Fig.  279). 

The  ends  of  the  silver  sutures  being  drawn  together,  and 
the  edges  of  the  wound  carefully  approximated,  each  thread 
is  slightly  twisted  so  as  to  keep  the  parts  in  apposition, 
and  then  the  ends  of  the  first  are  seized  with  forceps  and 
twisted  with  the  help  of  the  shield  (Fig.  275),  as  shown 
in  Fig.  278  ;  care  being  taken  not  to  twist  so  tightly  as 
to  strangulate  the  tissues  engaged  in  the  loop.  The  other 
sutures  are  then  twisted  in  the  same  manner,  and  the  ends 
of  each  cut  off  about  half  an  inch  from  the  surface  (Fig. 
280). 


FiG.   280. 


-MrMv 


The  bladder  is  then  syringed  to  remove  any  blood  that 
may  have  collected  in  it,  ami  a  catheter  passed  into  it  and 

left"    there. 

The  sutures  may  be  removed  during  the  second  week. 

Creation  of  <i  Veaico-vagirwl  Fistula. — Tin-  operation 
i-  sometimes  required  in  the  treatment  of  chronic  cystitis. 
Dr.  Knunet  '  perform-  it  as  follows:  Amestliesia  ;  Simp's 
position.  A  Sim-'-  speculum  is  introduced  into  the 
vagina  and  ;i  director,  abruptly  curved  an  inch  and  a- 

1  Chronic  CyBtitU  in  the  Female,  American  Practitioner,  February, 
l-7'_\  ;nnl  Veaico-vaginal  Fistula,  \>.  43. 


VESH 10-  VAO ISA  L  FISTULA . 


555 


half  from  its  extremity,  introduced  through  the  urethra. 
While  the  director  is  held  by  an  assistant  with  its  point 
firmly  pressing  in  the  median  line  against  the  base  of  the 
bladder  a  little  behind  the  neck,  the  surgeon  seizes  the 
projecting  tissue  on  the  vaginal  surface  with  a  tenaculum, 


Obliteration  of  the  vagina. 


and  exposes  the  beak  of  the  director  by  cutting  upon  it 
with  a  pair  of  scissors.  One  of  the  blades  of  the  scissors 
is  then  passed  through  the  opening  and  a  cut  made  back- 
ward in  the  median  line. 


556     GENITO-URINARY  ORGANS  OF  Till-:  FEMALE. 

If  the  opening  tends  to  close  spontaneously  too  soon,  a 
hollow  glass  stud  made  of  halt-inch  tubing  should  be  but- 
toned into  it.  The  vesical  rim  of  this  stud  need  not  be 
more  than  a  slight  flare,  the  vaginal  rim  should  be  larger. 

OBLITERATION    OF    THE   VAGINA;     KOLPOKLEISIS. 

(Fig.  2<S1.)  AVhen  a  vesieo-vaginal  fistula  cannot  be 
closed  by  the  means  above  described,  the  escape  of  urine 

Fi<;.  282. 


Emmet's  opera!  ion  for  procidenl  ia. 


may  be  prevented  by  closing  the  vagina.  Yidal  de  Cassis 
first  performed  this  in  is:;:;  by  effecting  union  between 
die   labia   majora,  but   it  has   been  found  that  complete 


ELYTRORRHAPHY. 


557 


closure  cannot  be  thus  obtained,  a  small  opening  remain- 
ing at  the  lower  angle.     Simon's  method  of  uniting  the 

anterior  and  posterior  walls  of  the  vagina  instead  of  the 
labia  is  much  more  trustworthy,  h  was  first  performed 
in  1855. 

A  strip  of  mucous  membrane  encircling  the  vagina  just 
below  the  fistula  is  removed,  the  opposing  raw  surfaces 
brought  together  by  sutures,  and  the  bladder  kept  empty 
by  a  catheter  until  union  has  taken  place. 


ELYTRORRHAPHY,    OR    NARROWING    OF    THE 
VAGINA. 

This  is  an  operation  intended  to  prevent  prolapse  of  the 
uterus.     The  method,  introduced  by  Sims,  of  removing  a 

Fig.  283. 


Colpo-perineorrhaphv  by  Hegar's  method.     (Pozzi.) 

longitudinal  strip  of  mucous  membrane  from  each  side  of 
the  vagina,  and   bringing  the   raw  surfaces  together,  has 


558     GENITO-URINABY  ORGANS  OF  THE  FEMALE. 


proved  not  only  inefficient,  but  often  actually  harmful  by 
supplying  a  pouch  in  which  the  cervix  became  engaged, 
thus  causing  extreme  retroversion.  Dr.  Emmet  avoided 
tin-  defect  by  closing  the  pouch  at  its  upper  end,  but  the 
mechanical  difficulties  in  the  way  of  performing  the  opera- 
tion are  so  great  that  he  has  substituted  for  it  another  in 
which  he  catches  up  on  a  tenaculum  three  folds  of  the 
vaginal  mucous  membrane,  one  on  each  side,  and  the  third 
in  front  of  the  cervix  (Fig.  282),  denudes  them  over  a 
space  half  an  inch  square,  and  draws  them  together  with 
a  suture.  The  three  folds  radiating  from  these  points  are 
then  pared,  and  united  stitch  by  stitch  along  the  anterior 
wall  of  the  vagina. 

Fro.  284. 


Colpo-perineorrhapby    by  Martin'*  method.     Bilateral  denudation  of  posterior 
vaginal  "nil ;  eon  tin -  sutures  in  layers.    (Pozzi.) 

Posterior  Elytrorrhaphy  or  Colporrhaphy.  (HeGAR'h 
Method.) — The  entire  thickness  of  a  portion  of  the  mu- 
cous membrane  is  removed  from  the  posterior  vaginal  wall 
in  the  form  of  an  isosceles  triangle  (Fig.  283),  with  its 


/,.  1  ( EK I  TED  ( EB  1 7  A".  559 

base  about  two  inches  broad  at  the  fourchette,  and  its 
apex  in  the  median  line  two  inches  above  the  fourchette. 
For  very  marked  prolapse  these  measurements  may  be 
extended  a  quarter  or  half  an  inch.  The  denuded  area  is 
folded  together  by  the  interrupted,  or  better  by  Martin's 
suture  as  described  for  perineorrhaphy. 

Martin's  Method.  (Fig.  284.) — Two  narrow  strips  of 
mucous  membrane  are  removed  from  the  posterior  vaginal 
Avail  on  each  side  of  the  median  line  from  just  below  the 
cul-de-sac  to  a  finger's  breadth  above  the  fourchette. 

The  operation  is  completed  by  perineorrhaphy  with 
Martin's  suture  throughout. 

Anterior. — A  portion  of  the  entire  thickness  of  the 
mucous  membrane  on  the  anterior  vaginal  wall  is  excised 
in  the  form  of  a  circle,  oval  or  diamond,  measuring  gen- 
erallv  about  an  inch  or  an  inch  and  a-half  in  its  ionei- 
tudinal  diameter,  and  situated  about  the  same  distance 
from  the  meatus. 

The  denuded  surface  is  folded  together  by  the  inter- 
rupted or  purse  string  or  Martin's  suture. 

LACERATED  CERVIX. 

Dr.  Thomas  Addis  Emmet1  was  the  first  to  point  out 
that  after  laceration  of  the  cervix  the  lips  rolled  out,  their 
mucous  membrane  became  eroded  by  contact  with  the 
floor  of  the  pelvis,  and  that  the  proper  method  of  treat- 
ment was  to  freshen  the  torn  surfaces  and  bring  them  to- 
gether with  sutures,  so  as  to  restore  to  the  cervix  its 
normal  size  and  form.  In  cases  which  have  long  re- 
mained unrecognized  or  untreated,  the  lips  become  cen- 
trally enlarged  by  the  inflammatory  process,  so  that  they 
cannot  be  properly  brought  together  until  after  the  re- 
moval of  a  thick  piece  on  each  side  of  the  inside  of  each 
lip  (Figs.  2<S5  and  286).  In  like  manner,  when  the 
eversion  is  increased  and  the  coaptation  of  the  lips  pre- 
vented by  cystic  degeneration  of  the  mucous  follicles  lin- 
ing the  cervical  canal,  free  punctures  must  be  made  with 

1  American  Journal  of  Obstetrics,  November,  1874. 


560     GENITO-UBINABY  ORGANS  OF  THE  FEMALE. 

the  point  of  a  knife  to  let  out  the  blood  and  the  contents 
of  the  cysts.  It  is  well  to  do  this  several  days  or  weeks 
before  the  operation,  apply  tincture  of  iodine  to  the  cer- 
vix, and  bring  the  lips  together  temporarily  by  putting  a 
plug  of  cotton  into  the  posterior  cul-de-sac  and  leaving  it 
there  for  several  hours  at  a  time.  The  puncturing  and 
application  of  iodine  must  be  frequently  repeated  until  the 
cysts  shall  have  all  disappeared  and  the  erosions  become 
nearly  or  entirely  healed. 

The  patient  is  placed  on  her  left  side,  a  Sims's  speculum 
introduced,  and  a  loop  of  wire  placed  around  the  cervix 
above  the  vaginal  reflection  and  tightened  by  drawing  its 


Fig.  285. 


Pig.  286. 


Lacerated  cervix,    side  view. 


Lacerated  cervix.    Showing  denuded  surface  (ill 
shaded  pari )  and  .sutures. 


ends  down  through  a  canula  so  as  to  prevent  bleeding  ;  or 
an  injection  of  hot  water  just  before  the  operation  will 
answer  the  same  purpose.  The  lips  are  then  separated 
and  the  lacerated  surfaces  thoroughly  freshened  with  curved 
or  angular  scissors  or  a  knife,  leaving  a  broad  undenuded 
strip  in  t  lie  center  to  form  the  Lining  of  the  restored  canal. 
This  strip  should  be  shaped  somewhat  like  an  hour-glass 
in  order  to  allow  for  the  shrinking  of  the  cervix  which 
follows  the  operation  (Fig.  286).  The  freshening  should 
lie  done  from  below  upward,  SO  that  the  blood  may  not 
interfere,  and  inii-l  lie  earned  deeply  enough  to  remove 
nil  diseased  glands  and  follicles. 


POSTERIOR  SE(  TION  OF  CERVIX. 


561 


A  tenaculum  is  then  engaged  in  each  lip,  and  the  two 
drawn  together;  if*  proper  coaptation  is  prevented  by  the 
central  enlargement  of  the  cervix  above  mentioned,  simple 
freshening  of  the  surface  is  not  sufficient,  but  a  greater 
thickness  of  tissue  must  be  removed.  The  freshening  at 
the  angles  of  the  fissure  should  be  superficial,  so  as  not  to 
involve  the  circular  artery  which  often  lies  just  at  that 
point. 

The  sutures  should  be  of  silver  Avire,  and  passed  with  a 
short,  round  needle  if  the  tissues  are  soft,  or  with  a  lance- 
shaped  one  if  they  are  dense  and  indurated.  From  three 
to  five  will  be  needed  on  each  side  if  the  laceration  is  ex- 
tensive and  double.  The  first  one  on  each  side  should  be 
entered  just  beyond  the  angle  of  the  fissure  so  as  to  include 
the  branches  of  the  circular  artery  if  necessary.  The 
needle  is  entered  on  the  outside  of  the  lip  and  brought  out 
at  the  edge  of  the  undenuded  strip  which  is  to  form  the 
canal,  and  then  passed  in  the  opposite  direction  (from 
within  outward)  at  corresponding  points  through  the 
other  lip.  Care  must  be  taken  to  obtain  accurate  approxi- 
mation along  the  vaginal  edge,  but  the  inner  edges  of  the 
denuded  surface-  do  not  require  attention. 

POSTERIOR    SECTION    OF    THE    CERVIX. 

This  operation  may  be  rendered  necessary  by  irreducible 
flexion  of  the  uterus.      The  patient  being  placed  in  position 

Fig.  287. 


Sims'>  knife. 


and  a  Sims's  speculum  introduced,  the  cervix  is  fixed  by  a 
tenaculum  and  its  posterior  lip  divided  with  scissors  as 
high  as  to  the  vaginal  junction.  The  blade  of  a  Sims's 
knife  (Fig.  287)  is  then  introduced  through  the  os  inter- 
36 


562     GENITO-TJRINARY  ORGANS  OF  THE  FEMALE. 

mini,  and  the  tissues  cut  so  as  to  lay  open  the  pos- 
terior wall  of  the  cervix  (Fig.  288).  The  blade  is  then 
turned  toward  the  anterior  wall,  and  the  little  shoulder 
which,  as  Dr.  Emmet  has  pointed  out,  usually  exists  there 
at  the  point  of  flexion  is  cut  through.  Instead  of  making 
this  second  incision  Dr.  Wylie  practises  and  recommends 
divulsion  with  a  strong  steel  dilator. 

Fig.  288. 


1  :steri2r  section  cf  the  cervix 


A  roll  of  cotton  saturated  with  a  solution  of  persul- 
phate of  iron,  one  part  to  two  of  water,  is  placed  so  as 
to  occupy  the  whole  cervix,  and  retained  by  a  plug  of 
wet  cotton  in  the  vagina. 


OPERATIONS    ON    THE    UTERUS  AND  ADNEXA. 

Anatomy. — The  broad  ligaments,  consisting  of  two 
layer-  of  peritoneum,  continuous  with  that  which  covers 
the  uterus,  are  attached  to  its  sides  from  the  eornua  to 
the  level  of  the  internal  os;  externally  they  are  attached 
to  the  aides  of  the  pelvis  in  a  vertical  but  broader  line, 
about  midway  between  the  obturator  foramen  and  the 
great  sciatic  notch.     The   Fallopian   tube  passes  outward 


OPEEATIOXS  OF  UTERUS  AND  ADNEXA.       563 

from  the  angle  of  the  uterus  in  the  highest  part  of  the 
broad  ligament,  while  in  front  and  a  little  lower  down  the 
round  ligament  diverges  to  the  internal  abdominal  ring, 
and  contains  a  branch  of  the  epigastric  artery  passing  to 
the  uterus.  Behind  the  Fallopian  tubes  are  the  ovaries 
which  are  subject  to  great  variation  in  position — normally 
each  occupies  the  apex  of  a  ligamentous  triangle  directed 
backward,  the  base  of  which  is  in  the  broad  ligament, 
and  through  which  the  branches  of  the  ovarian  artery  and 
the  pampiniform  plexus  of  veins  enter  the  gland.  The 
inner  angle  of  the  ligamentous  triangle  passing  to  the 
fundus  of  the  uterus  is  a  rounded  fold  of  peritoneum  con- 
taining muscular  liber,  and  called  the  utero-ovarian  liga- 
ment. The  outer  angle  blends  with  the  upper  border  of 
the  broad  ligament,  and  is  called  the  infundibulo-pelvic 
ligament. 

The  ovarian  arteries  arise  from  the  abdominal  aorta, 
and  at  the  brim  of  the  pelvis  cross  the  bifurcation  of  the 
common  iliac  vessels  and  the  ureter,  and  run  in  a  tortu- 
ous course  in  the  upper  border  of  the  broad  ligament,  or 
more  exactly  in  the  infundibulo-pelvic  ligament,  to  the 
cornua  of  the  uterus,  where  they  anastomose  with  the 
uterine  arteries  along  the  respective  sides.. 

Each  ureter  crosses  the  common  iliac  artery  near  its 
bifurcation,  and  runs  from  behind  downward,  forward, 
and  inward  in  front  of  the  internal  iliac  artery  and  its 
anterior  division,  lying  in  the  base  of  the  broad  ligament, 
which  is  limited  by  the  levator  ani  muscle.  Xear  the 
level  of  the  external  os  the  ureter  is  crossed  on  its  inner 
side  by  the  uterine  artery,  and  then  runs  along  the  side 
of  the  vagina  about  half  an  inch  from  the  cervix,  entering 
the  bladder  just  above  the  middle  of  the  anterior  vaginal 
wall.  The  uterine  artery  arises  from  the  anterior  trunk 
of  the  internal  iliac  near  the  synchondrosis,  and  passes 
downward  and  forward  to  a  point  just  above  the  spine  of 
the  ischium,  where  it  leaves  the  pelvic  wall,  but  still  de- 
scends almost  to  the  tuberosity  of  the  ischium  ;  it  then 
turns  up  toward  the  vagina,  reaching  the  uterus  at  the 
utero-vaginal  junction.     Opposite  the  external  os  it  gives 


564     GEX1T0-UBIXARY  ORGANS  OF  THE  FEMALE. 

off  the  circular  artery  of  the  cervix  and  continues  along 
the  side  of  the  uterus  between  the  layers  of  the  broad 
ligament,  and  at  the  superior  cornu  it  anastomoses  with 
the  ovarian  artery. 

The  peritoneum  is  firmly  adherent  to  the  fundus  of  the 
uterus,  but  gradually  becomes  more  loosely  attached  until 
it  can  be  readily  stripped  up  with  the  finger  in  the  vesico- 
uterine depression.  Posteriorly  it  descends  about  three- 
quarters  of  an  inch  on  the  vaginal  wall,  and  is  likewise 
easily  peeled  off  to  the  same  level  as  in  front.  With  a 
normal  uterus  and  an  empty  bladder,  the  latter  lies  upon 
the  cervix  for  about  half  an  inch. 

OVARIOTOMY. 

The  patient  is  prepared  in  the  usual  way  for  a  lapar- 
otomy, and  immediately  before  the  operation  she  is  cathe- 
terized,  the  sponges,  pads,  and  clamps  are  counted  and  the 
number  of  each  written  down.  An  incision  three  or  four 
inches  long  is  made  in  the  median  line  between  the  umbil- 
icus  and  the  pubes,  which,  if  necessary,  is  later  extended 
upward  with  a  slight  semicircular  deviation,  including  the 
umbilicus  and  passing  to  the  left  of  it  to  avoid  the  falci- 
form ligament.  The  incision  is  deepened  layer  by  layer 
and  the  peritoneum  first  opened  above  by  pinching  up  a 
fold  with  the  fingers  or  forceps  and  nicking  it,  and  then 
enlarging  it  downward  by  cutting  on  the  fingers  inside  as 
a  director,  care  being  taken  to  avoid  the  bladder,  which 
may  be  recognizable  from  within  as  a  thickened  fold  lying 
near  the  pubes. 

When  the  peritoneum  is  adherent  to  the  tumor  it  may 
be  simpler  to  prolong  the  incision  above  the  latter  to  make 
certain  that  the  abdominal  cavity  has  been  opened  and  that 
the  peritoneum  is  not  simply  stripped  from  the  parieties. 
Sometimes,  also,  the  bladder  is  drawn  far  up  above  its 
usual  position,  but  it  can  be  recognized  by  its  vascularity 
or  by  a  sound  passed  in  through  the  urethra.  A  sponge 
protective  packing  is  wedged  around  the  exposed  cyst, 
which  is  then   punctured  with  a  large  trocar  and  eanula, 


OVARIOTOMY.  565 

the  latter  being  provided  with  a  tube  to  conduct  the  fluid 
to  one  side,  and  as  soon  as  possible  the  walls  are  grasped 
by  the  fingers  or  by  forceps  and  drawn  into  the  wound, 
while,  at  the  same  time,  pressure  is  made  on  the  parieties, 
or  the  patient  is  rolled  on  one  side  to  favor  the  escape  of 
the  contents.  If  the  latter  are  too  thick  to  flow  readily, 
the  puncture  may  have  to  be  enlarged  sufficiently  to  per- 
mit them  to  be  scooped  out  by  hand,  and  through  this 
opening  other  loculi  are  entered  by  the  finger,  knife,  or 
trocar,  and  enough  liquid  evacuated  to  permit  of  an  at- 
tempt to  turn  the  cyst  out  of  the  abdomen. 

The  adhesions  are  cautiously  separated  by  the  finger- 
nail and  blunt-pointed  scissors  or  divided  between  double 
catgut  ligatures. 

The  peritoneal  cavity  must  be  constantly  protected  by 
the  addition  of  fresh  sponges  as  the  dissection  progresses, 
though  usually  no  harm  follows  from  the  escape  into  it 
of  some  of  the  cyst-contents.  When  the  pedicle  has  been 
fully  exposed,  often  by  bringing  the  cyst  out  of  the  belly, 
if  broad  it  is  secured  in  sections  by  the  interlocking  silk 
ligature  passed  on  a  blunt-pointed  aneurism  needle,  and 
the  tumor  or  what  remains  of  it  is  excised  ;  or  the  pedicle 
may  be  divided  with  scissors  and  the  vessels  secured  as 
they  are  encountered  by  clamps,  and  after  removal  of  the 
tumor  ligated  separately. 

A  comparatively  small  pedicle  can  be  ligated  en  masse 
with  stout  silk,  but  it  is  well  also  to  secure  by  separate 
ligatures  the  vessels  that  appear  on  the  cut  surface. 

If  there  have  been  few  or  no  adhesions  and  the  cyst  has 
been  removed  practically  without  opening  it,  the  abdomi- 
nal wound  can  be  closed  entirely  in  the  usual  way,  after 
taking  out  and  counting  the  sponges  and  clamps.  But 
drainage  by  rubber  tubes  and  iodoform-gauze  packing  is 
imperative  whenever  there  is  even  a  possibility  of  infec- 
tion, and  especially  if  a  portion  of  the  cyst  wall  has  been 
necessarily  left  behind  owing  to  its  too  firm  adhesion  to 
important  structures.  If  there  has  been  much  peritoneal 
laceration  accompanied  by  oozing  from  minute  blood- 
vessels, drainage  and   hemostasis  are  conveniently  pro- 


566     GENITO-URIXARY  ORGANS  OF  THE  FEMALE. 

vided  for  by  a  large  sheet  of  iodoform  gauze  placed 
in  contact  with  the  lacerated  surface  and  having  all  its 
edges  brought  out  of  the  abdominal  wound. 

This  pouch  is  then  stuffed  with  strips  of  gauze  which 
are  subsequently  removed  one  by  one,  to  gradually  reduce 
its  bulk.  The  parietal  opening  is  partially  closed  and 
dressed  antiseptically  in  the  usual  way. 

OOPHORECTOMY. 

This  term  is  used  to  designate  the  removal  of  macro- 
scopically  normal  ovaries  and  Fallopian  tubes  for  hemo- 
static or  analgesic  purposes. 

After  the  usual  preliminaries,  including  catheterization, 
the  patient  is  placed  in  Trendelenburg's  position,  which 
greatly  facilitates  all  intra-abdominal  operations  on  the 
pelvic  organs. 

An  incision  about  three  inches  long  is  made  in  the  me- 
dian line  above  the  pubes,  and  deepened  layer  by  layer  till 
the  peritoneal  cavity  is  opened.  Two  fingers  are  passed 
through  the  incision  to  the  fundus  of  the  uterus  and  thence 
outward,  following  one  Fallopian  tube  to  its  extremity, 
which  is  drawn  up  into  the  abdominal  wound  together 
with  the  ovary.  Flat  sponges  are  placed  around  them, 
and  a  ligature  is  placed  about  the  ovarian  artery  and  veins 
at  the  edge  of  the  broad  ligament.  Others  are  placed  upon 
the  tube  and  the  utero-ovarian  ligament  close  to  the  uterus. 
The  tissues  distal  to  these  ligatures  are  then  cut,  and  the 
intermediate  portion  of  the  broad  ligament  tied  in  one  or 
two  ligatures.  The  ovary  and  tube  are  then  excised,  and 
after  a  final  inspection  of  the  pedicle  for  hemorrhage  it  is 
dropped  back  into  the  abdomen. 

The  same  proceeding  is  repeated  upon  the  other  side, 
the  flat  sponges  are  removed,  and  finally  the  abdominal 
incision  is  closed  tight  in  the  usual  way  and  dressed  with- 
out drainage. 


SALPINGO-OOPHORECTOM  Y.  567 

SALPINGO-OOPHORECTOMY,  OR  THE  REMOVAL  OF  A 
TUBE  DISTENDED  WITH  PUS,  AND  ITS  OVARY. 

After  the  usual  preliminaries,  including  antiseptic  vagi- 
nal douches,  the  patient  is  catheterized  and  placed  in 
Trendelenburg's  position,  as  described  for  oophorectomy. 
An  incision  not  less  than  four  inches  long  is  made  in  the 
median  line  above  the  pubes,  afterward  extended,  if  neces- 
sary, around  the  umbilicus  to  afford  plenty  of  room  for 
manipulation.  The  incision  is  deepened  layer  by  layer, 
the  bleeding  stopped,  and  the  peritoneum  nicked  in  the 
upper  angle  of  the  wgund  and  opened  downward  on  the 
finger  as  a  guide,  stopping  short  of  the  bladder,  which  can 
be  recognized  on  the  inside  as  a  thickened  fold  near  the 
pubes  ;  or,  if  there  is  any  doubt,  by  a  sound  passed  through 
the  urethra.  The  omentum  and  intestines  are  pushed 
back,  separating  adhesions  with  the  finger-nail  or  blunt- 
pointed  scissors,  till  there  is  a  full  exposure  of  the  uterus 
and  its  appendages,  which  are  then  surrounded  with  flat 
sponges  or  pads,  completely  shutting  off  the  rest  of  the 
peritoneal  cavity. 

The  fingers  are  passed  outward  from  the  fundus  of  the 
uterus,  following  every  crevice  around  first  one  tube  and 
then  the  other,  till  some  spot  is  found  where,  by  slight 
pressure  or  tearing,  the  tip  of  the  index-finger  can  be 
worked  under  or  around  the  mass  and  the  tube  freed,  gen- 
erally in  company  with  its  ovary.  If  pus  should  be  dis- 
covered escaping,  the  dissection  is  stopped  till  it  has  been 
entirely  sponged  away,  enlarging,  if  necessary,  the  hole 
from  which  it  comes.  The  somewhat  free  oozing  is  con- 
trolled by  sponge  packing,  and  when  a  more  or  less  dis- 
tinct pedicle  has  been  formed,  or  the  finger  recognizes  a 
dangerous  amount  of  resistance  to  its  progress,  the  strip- 
ping up  and  gently  tearing  process  is  stopped. 

With  a  blunt-pointed  aneurism  needle  a  stout  catgut 
ligature  is  then  passed  under  the  infundibulo-pelvic  liga- 
ment, or  the  outer  attachment  of  the  freed  mass  consisting 
of  the  ovary  and  diseased  tube,  tying  off  this  ligament 
close  to  the  mass  and  including  the  ovarian  artery,  the 


568     GENITO-UBINARY  ORGANS  OF  THE  FEMALE. 

position  of  which  can  be  ascertained  in  advance  by  pal- 
liating the  broad  ligament  and  noting  the  pulsation. 

Another  catgut  ligature  is  passed  through  the  broad 
ligament  in  the  angle  formed  by  the  junction  of  the  uterus 
and  Fallopian  tube,  and  the  latter  is  secured  with  the 
termination  of  the  artery  close  to  the  uterus. 

Beginning  on  the  uterine  side  of  the  outer  ligature,  the 
tissues  attached  to  the  under  side  of  the  tube  are  cut  with 
blunt-pointed  scissors,  clamping  each  vessel  or  bleeding 
point  as  it  is  encountered,  and  in  this  way,  when  the  tube 
alone  is  diseased,  it  is  generally  easy  to  leave  the  ovary 
undisturbed,  and  tins  is  always  done  by  some  surgeons  ; 
but  in  such  an  instance  there  should  be  no  preliminary 
ligature  of  the  infundibulo-pelvic  ligament  with  the  ovar- 
ian artery,  and  the  scissors  must  be  kept  close  to  the  tube, 
while  bleeding  is  controlled  by  individual  ligature  of  each 
vessel  as  it  is  cut. 

The  diseased  mass  is  then  excised  on  the  distal  side  of 
the  ligature  next  to  the  uterus  and  the  stump  disinfected. 
Before  its  division  the  tube  is  secured  by  a  clamp  to  pre- 
vent the  escape  of  pus  if  it  has  not  already  occurred. 

Ligature  en  masse  of  the  pedicle,  which  is  almost  always 
bulky,  is  only  mentioned  to  be  condemned.  After  chang- 
ing the  sponges  and  securing  any  vessels  which  still  bleed, 
the  cut  edges  of  peritoneum  forming  the  broad  ligament 
are  united  with  fine  catgut  sutures  over  the  denuded  area 
which  lies  under  the  Fallopian  tube, and  when  it  has  been 
possible  to  perform  the  operation  without  the  escape  of  a 
drop  of  pus,  and  without  leaving  a  large  oozing  surface, 
the  protective  3ponges  arc  removed  and  the  abdominal 
wound  closed  tight  in  the  usual  way. 

Otherwise  the  peritoneal  cavity  is  made  as  clean  and 
dry  as  possible  and  rubber  tubes  with  lateral  perforations 
arc  placed  in  the  suspected  regions,  with  one  always  in 
Douglas's  pouch,  and  surrounded  by  strips  of  iodoform 
gauze,  around  the  ends  of  which  the  abdominal  wound  is 
partially  closed. 

Sometimes  the  Fallopian  tube  will  be  found  changed 
into  an  abscess  sac,  with  very  firm  adhesions,  which  only 


TUMORS  BENEATH  BROAD  LIGAMENT.  569 

permit  the  sac  to  be  opened,  or  not  more  than  partially 
removed  ;  very  rarely  it  can  be  only  partially  exposed, 
but  the  pus  can  always  be  reached  somewhere  by  a  care- 
ful dissection,  aided  possibly  by  a  guiding  puncture  with 
an  aspirating  needle.  The  surrounding  parts  are  then 
carefully  protected  by  a  sponge  packing  and  the  abscess 
cavity  thoroughly  evacuated  and  washed  out  with  boiled 
water,  and  drained  with  rubber  tubes  and  iodoform  gauze. 
Communication  between  the  abdominal  wound  and  the 
opening  in  the  sac,  which  may  be  at  a  distance  from  the 
surface,  is  maintained  by  packing,  which  should  also  ex- 
tend into  and  protect  all  possibly  infected  regions  around 
the  abscess.  Aided  by  an  exploring  finger  in  the  vagina 
it  will  sometimes  be  possible  and  very  advisable  to  force 
a  blunt-pointed  forceps  from  the  bottom  of  the  abscess 
cavity  into  the  posterior  fornix,  and  thus  pass  a  tube  to 
afford  drainage  in  the  most  dependent  regions  as  well  as 
from  the  surface  of  the  abdomen.  The  vagina  is  packed 
around  the  tube  and  a  dressing  is  placed  on  the  vulva, 
while  every  precaution  is  taken  to  prevent  infection  from 
the  urine  and  feces. 

If  the  vermiform  appendix  is  found  involved  or  ad- 
herent to  a  diseased  tube,  as  often  happens,  it  should  be 
excised  at  the  same  time.  Whenever  in  a  case  in  which 
the  abdominal  wound  has  been  closed  tight  symptoms  of 
secondary  hemorrhage  appear,  the  diagnosis  should  be  at 
once  verified  by  untying  a  stitch  in  the  lower  angle  ot 
the  wound  and  passing  a  small  sponge  on  a  holder  into 
Douglas's  pouch.  If  done  with  every  antiseptic  precau- 
tion this  exploration  is  free  from  danger,  even  if  no 
hemorrhage  is  found. 

TUMORS   LYING  BENEATH  THE  BROAD  LIGAMENT. 

An  opening  is  made  in  the  overlying  peritoneum  gen- 
erally in  front  of  the  Fallopian  tube,  and  through  this 
the  dissection,  guided  by  the  sense  of  touch,  is  carried 
out  by  the  tip  of  the  finger  tearing  through  the  loose  con- 
nective tissue  surrounding  the  capsule  of  the  tumor,  and 


570     QENITO-JJBINART  ORGANS  OF  THE  FEMALE. 

the  latter  enucleated.  The  few  vessels  are  clamped  as 
they  are  encountered  and  tied  later,  and  drainage  is  pro- 
vided for  as  after  salpingo-oophorectomy. 

OPERATIONS  FOR  ECTOPIC  GESTATION. 

In  the  early  stages  of  this  condition  before  the  placenta 
has  formed,  the  operation  is  conducted,  according  to  the 
situation  of  the  mass,  in  the  same  way  as  in  ovariotomy  or 
salpingo-oophorectomy,  or  for  a  tumor  lying  below  the 
broad  ligament. 

Later,  after  the  formation  of  the  placenta,  the  general 
rule  is  to  open  the  abdomen  in  the  median  line  below  the 
umbilicus,  and,  after  protecting  the  peritoneal  cavity  by  a 
sponge  packing,  the  sac  is  entered  in  front  like  an  ovarian 
cyst,  avoiding  if  possible  the  site  of  the  placenta,  which  can 
usually  be  recognized  by  the  surrounding  vascularity.  But 
sometimes  the  placenta  may  have  to  be  perforated,  and 
then  the  hemorrhage  from  it  is  controlled  by  clamps  or 
deep  sutures. 

The  foetus  and  amniotic  liquid  are  extracted  while  the 
surrounding  parts  are  well  guarded,  and  when  it  seems 
perfectly  feasible  the  sac  may  be  dissected  out  with  the 
placenta,  separating  adhesions  with  the  tip  of  the  finger  or 
blunt-pointed  scissors  and  arresting  the  bleeding  as  it  oc- 
curs ;  but  more  often  the  complete  removal  is  impossible, 
and  the  opening  in  the  sac  is  either  stitched  to  the  margins 
of  the  abdominal  wound  or  kept  in  communication  with  it 
by  packing  and  drainage  applied  on  the  principles  already 
enunciated,  while  the  placenta  is  left  to  slough  away  with 
the  attached  umbilical  cord. 

If  the  operation  is  performed  for  hemorrhage  following 
rupture  of  an  extra-uterine  gestation,  the  abdomen  is 
opened  in  the  same  way  and  one  hand  passed  to  the  fun- 
dus of  the  uterus  and  thence  outward  to  the  boggy  mass, 
which,  if  it  can  be  raised  to  the  surface,  is  easily  secured  and 
treated.  But  if  this  is  impossible,  an  attempt,  guided  by 
the  hand  inside  the  belly,  is  made  to  seize  one  or  both  ex- 
tremities of  the  broad  ligament  with  its  contained  vessels, 
by  long-bladed  clamps. 


HYSTEROPEXY. 


571 


The  blood  and  dibria  arc  then  rapidly  scooped  out  of  the 
peritoneal  cavity  and  a  search  is  made  for  bleeding  points, 
which  are  immediately  caught  and  tied,  and  then  a  decision 
can  be  made  as  to  extirpation  of  the  sac,  which  does  not 
differ  from  an  inherent  tube  or  an  ovarian  cyst,  except 
that  the  placenta  in  the  great  majority  of  cases  should  not 
be  disturbed. 

The  treatment  of  a  case  in  which  suppuration  has 
occurred  does  not  differ  from  that  of  an  intra-abdominal 
or  pelvic  abscess. 

HYSTEROPEXY. 

The  peritoneal  cavity  is  opened  by  a  median  incision 
of  about  three  inches  just  above  the  pubes,  and  the  fundus 
of  the  uterus  is  brought  up  to  the  abdominal  wall,  to 
which  it  is  fixed  by  three  silk  or  silkworm -gut  sutures 
passed  transversely  across  the  fundus  and   front  of  the 

Fig.  289. 


uterus,  within  the  substance  of  which  they  are  buried  for 
about  an  inch,  and  then  through  the  parietal  peritoneum 
and  muscles  and  tied  in  the  wound  (Fig.  289).  The  uter- 
ine peritoneum  covering  the  sutures  should  be  scraped 
slightly  to  provoke  adhesions.     Some  carry  the  sutures 


572     OENITO-VRTNARY  ORGANS  OF  THE  FEMALE. 

entirely  through  the  abdominal  wall,  tie  them  outside  and 
remove  them  after  a  fortnight. 

INTRA-ABDOMINAL  SHORTENING  OF  THE  ROUND 
LIGAMENTS. 

Wylie  opens   the   abdomen   in   the    median    line  and 
shortens  the  round  ligaments  as  shown  in  Fig.  290.     Polk 

Fig.  290. 


Hysteropexy.    Wylie's  method  of  shortening  the  round  ligaments. 

ties  the  two  ligaments  together  in  front  of  the  uterus,  so 
that  they  form  an  X- 


ALEXANDER'S  OPERATION1   FOR    SHORTENING    THE 
ROUND  LIGAMENTS. 

With  every  antiseptic  precaution  an  oblique  incision  an 
inch  and  a-half  or  two  inches  long  is  made  over  the  inguinal 
canal  terminating  near  the  spine  of  the  pubis.  The  exter- 
nal abdominal  ring  is  cleared  and  the  inter-columnar  fascia 
is  divided,  exposing  the  fine  yellow  fat  in  which  the  red- 
dish cord-like  round  ligament  will  be  found  near  the  up- 
per limit  of  the  external  abdominal  ring.  The  other  side 
i-  treated  in  the  same  manner. 

A  -light  dissection  may  be  necessary  to  isolate  the 
round  ligament,  and,  aided  by  a  sound  in  the  cavity  of  the 
uterus,  enough  traction  is  made  on  the  cords  to  raise  the 
uterus  to  the  desired   position.     Often  four  or  five  inches 

'Liverpool  Med.-Chir.  Journ.,  January,  1883,  p.  113. 


LAPARO-IIYSTEROTOMY.  573 

of  the  round  ligament  can  thus  be  easily  drawn  out 
through  the  ring. 

The  ligaments  on  each  side  are  held  in  their  new  posi- 
tion by  a  couple  of  sutures  of  catgut  or  silkworm-gut 
passed  through  them  and  the  external  and  internal  pillars 
of  each  ring.  The  wound  in  the  intereolumnar  fascia  is 
closed  with  fine  catgut  and  the  external  wound  is  sutured 
and  dressed  antiseptieally  without  drainage. 

Tampons  or  pessaries  must  be  worn  for  a  month. 

LAPARO-HYSTEROTOMY. 

By  this  term  is  meant  the  making  of  an  opening  into 
the  cavity  of  the  uterus  for  any  purpose,  commonly  the  ex- 
traction of  a  foetus.  In  the  latter  instance  the  time  of 
election,  according  to  Senn,1  is  during  the  first  stage  of 
labor. 

The  patient  is  catheterized,  and  with  every  antiseptic 
precaution,  including  preliminary  antiseptic  douches  for 
the  vagina,  an  incision  about  six  inches  long  is  made  in 
the  median  line  above  the  pubes,  and,  bearing  in  mind 
that  the  abdominal  wall  is  apt  to  be  very  thin  and  that  the 
enlarged  uterus  is  in  contact  with  it  without  the  interposi- 
tion of  other  viscera,  the  incision  is  cautiously  deepened 
layer  by  layer  till  the  peritoneal  cavity  is  opened  in  the 
whole  extent  of  the  wound  and  the  surface  of  the  uterus 
exposed. 

Sponges  are  packed  around  the  latter  and  a  longitu- 
dinal incision  about  an  inch  long  is  made  in  its  anterior 
wall  at  a  point  midway  between  the  junction  of  the  Fallo- 
pian tubes  with  the  uterus.  To  lessen  the  hemorrhage 
this  incision  is  enlarged  downward  by  tearing  sufficiently 
to  extract  the  child,  head  first,  which  must  be  done  as  rap- 
idly as  possible  after  rupturing  the  membranes.  As  the 
bleeding  is  most  free  from  the  cervical  region,  the  rent 
must  not  approach  this  too  closely. 

The  uterus  is  immediately  turned  out  of  the  abdomen 
and  protected  by  a  warm  towel,  and  its  neck  below  the 
opening  constricted  by  an  elastic  ligature  tightly  enough 
1Amer.  Journ.  Med.  Sci.,  Sept.,  1893. 


574     GENJT0-UR1NARY  ORGANS  OF  THE  FEMALE. 


to  arrest  the  bleeding;.  The  placenta  is  next  peeled  off 
with  its  attached  membranes,  and  after  cleansing  the  in- 
terior of  the  uterus  the  rent  is  closed  by  a  row  of  inter- 
rupted stout  catgut  sutures  passed  at  intervals  of  half  an 
inch  through  the  entire  thickness  of  the  uterine  wall,  ex- 
clusive of  the  peritoneum,  and  about  half  an  inch  from 
the  torn  edge. 

Another  sow  of  sutures  is  placed  between  these  in  the 
same  way,  but  including  only  half  the  muscular  thick- 
ness and  these  are  covered  in  by  a  row  of  catgut  Lembert 

Fig.  291. 


<  losure  of  the  uterine  wound  after  Cesarean  section.    A.  reritoneuru.    B.  Mus- 
cular wall  of  the  uterus. 

sutures  which  should  pass  through  enough  of  the  muscular 
tissue  to  secure  good  peritoneal  apposition  over  the  line  of 
suture.     (Fig.  291.) 

The  abdominal  cavity  is  cleansed  and  the  elastic  liga- 
ture removed  from  the  uterus,  but  the  latter  is  not  replaced 
in  the  belly  until  after  contraction  has  occurred  or  been 
induced  by  pressure,  rubbing,  or  the  subcutaneous  injec- 
tion of  ergot.  The  abdominal  wound  is  then  closed  tight 
in  the  usual  way  and  dressed  without  drainage,  and  an 
iodoform-gauze  packing  is  placed  in  the  interior  of  the 
litem-  from  the  vagina. 

SYMPHYSIOTOMY.1 

The  patient  is  eatlieteiized,  and,  after  thorough  disinfec- 
tion of  the  abdominal    wall   and   the  external   genitals,  a 

1  Aforisani  :    Ann.  dc  Gynec.  el  d'Obst.,  April,  1892,  p.  241.    Char- 

pentier:   Hull.  <i...  I'A.-.ul.  "do  Mod.,  Mun-h,  ik-.cj,  ,,.  :{52. 


MYOMECTOMY.  575 

longitudinal  incision  two  or  throe  inches  long  is  made 
over  the  symphysis  and  carried  down  to  the  bone. 

The  origin  of  one  pyramidalis  muscle  is  divided  suffi- 
ciently to  admit  the  index-finger,  which  is  inserted  behind 
the  pubes,  separating  and  pushing  back  from  the  bone  the 
prevesical  tissues  and  on  this  finger  as  a  guide  the  sym- 
physis, which  usually  is  not  exactly  in  the  middle  line,  is 
divided  by  a  probe-pointed  cartilage  knife  from  above  and 
behind  downward  and  forward,  sparing  if  possible  the  liga- 
mentum  arcuatum  or  triangular  ligament.  A  sound  is 
sometimes  first  placed  in  the  urethra  and  bladder  to  draw 
them  to  one  side. 

After  extraction  of  the  child,  per  vias  naturales,  the 
pubic  bones  can  be  reunited  by  buried  silk  sutures,  or  the 
wound  may  be  closed  by  silk  sutures  passed  through  the 
skin  and  the  anterior  portion  of  the  symphysis.  But  it 
will  generally  be  found  sufficient  to  insert  simple  super- 
ficial sutures  and,  after  dressing  the  wound  antiseptically, 
to  immobilize  the  pelvis  by  a  stout  binder  or  bandage. 

MYOMECTOMY,   OR    THE    REMOVAL   OF  A  SUBPERI- 
TONEAL FIBROID   TUMOR  OF  THE  UTERUS. 

The  abdomen  is  opened  as  usual  in  the  median  line  be- 
low the  umbilicus  sufficiently  to  admit  the  hand,  and  after 
exploration  the  incision  is  enlarged  if  necessary,  and  ad- 
hesions carefully  separated  or  divided  between  double  cat- 
gut ligatures.  The  rest  of  the  peritoneal  cavity  is  shut 
off  by  a  sponge  protective  packing,  and  when  the  growth 
has  a  distinct  pedicle  the  latter  is  simply  surrounded  by  a 
silk  ligature  which  may  in  addition  first  transfix  the  pedicle 
if  it  is  large,  and  the  growth  is  excised  ;  or,  when  there  is 
no  pedicle  and  the  tumor  is  sharply  defined,  two  semilunar 
flaps  are  cut  from  the  peritoneum  on  its  base,  and  through 
the  gap  thus  made  the  tumor  enucleated  by  the  tip  of  the 
finger  or  blunt-pointed  scissors. 

The  vessels,  which  are  principally  superficial,  are 
clamped  and  tied  as  they  are  encountered,  and  if  there 
is  bleeding  from  vessels  buried  in  the  base  it  can  be  con- 
trolled by  a  deep  catgut  suture  passed  on  a  curved  needle. 


576     GENITO-UBINABY  ORGANS  OF  THE  FEMALE. 

The  peritoneal  flaps  are  closed  over  the  denuded  sur- 
face with  fine  catgut,  and  if  it  seems  advisable  after  re- 
moval of  the  sponge  protectives  an  iodoform-gauze 
packing  is  placed  in  contact  with  any  region  where 
hemorrhage  or  infection  is  possible,  and  the  abdominal 
wound  is  partially  closed  around  the  ends  of  the  gauze. 
When  all  goes  well  this  packing  is  removed  after  twenty- 
tour  or  forty-eight  hours,  and  the  gap  is  then  closed  by 
a  stitch  inserted  for  this  purpose  at  the  time  of  the 
operation. 

ABDOMINAL  HYSTERECTOMY.1 

After  rendering  the  vagina  aseptic,  the  patient  is 
catheterized  and  placed  in  Trendelenburg's  position  and 
a  median  incision  about  eight  inches  long  is  made  above 
the  pubes  and  deepened  layer  by  layer  till  the  abdomen 
is  opened.  The  intestines  are  covered  and  pushed  back 
from  the  pelvis  by  flat  sponges  or  pads,  and  the  ovarian 
artery  and  vessels  tied  on  each  side  at  the  free  border  of 
the  broad  ligament.  The  uterine  arteries  are  next  iso- 
lated and  tied  low  down  near  the  cervix  after  recognizing 
their  position  by  palpation  of  the  broad  ligament  with  the 
thumb  and  finger  close  to  the  uterus  ;  an  opening  is  made 
in  the  posterior  (sometimes  the  anterior)  layer  of  the 
broad  ligament,  and  an  aneurism  needle  passed  about  the 
artery.  After  the  four  arteries  have  been  thus  secured, 
the  broad  ligaments  are  cut  across,  and  the  peritoneal 
portions  of  the  incisions  carried  across  the  front  and  back 
of  the  uterus,  in  front  just  above  the  vesical  reflection, 
and  behind  at  about  the  level  of  the  internal  OS.  Then  by 
dissecting  down  with  knife  or  scissors  between  the  uterus 
and  bladder,  aided  by  lli<'  finger  of  an  assistant  in  the  va- 
gina, the  vagina  is  readied  and  opened  in  the  anterior 
fornix.     The  peritoneum  on   the  back  of  the  cervix  is 

next  dissected  down  lor  some  distance,  and  then,  with  the 
finger  as  a  guide  in  the  opening  in  the  anterior  fornix, 
the  incision  is  carried  around  the  cervix,  and  the  uterus 
and  appendages  thus  removed. 

■Stimaon.     Medical  News,  July  27,  1889. 


ABDOMINAL  HYSTERECTOMY.  577 

Instead  of  tying-  the  uterine  arteries  as  above  described, 
a  long  clamp  may  be  placed  in  the  broad  ligament  below 
and  parallel  to  the  tube  after  the  ovarian  artery  has  been 
tied  (to  prevent  venous  bleeding),  the  broad  ligament  cut 
across  below  it,  and  the  artery  sought  for  and  tied  deep 
between  its  cut  edges.  The  operation  is  then  continued 
as  above. 

(If  it  is  desired  to  preserve  one  or  both  tubes  and 
ovaries,  the  first  ligatures  should  be  placed  not  about  the 
ovarian  arteries  but  about  the  tubes  close  to  the  uterus, 
and  the  broad  ligament  divided  downward  beside  the 
uterus.) 

After  removal  of  the  uterus,  the  cut  edge  of  the  vagina 
in  front  and  behind  is  sutured  to  the  corresponding  cut 
edge  of  the  peritoneum,  and  the  sides  of  the  broad  liga- 
ments sewed  together  with  a  continuous  suture ;  a  drain 
of  iodoform  gauze  is  placed  in  the  vagina,  part  of  it  ex- 
tending into  the  peritoneal  cavity  and  part  under  the 
broad  ligament,  and  the  anterior  abdominal  wound  is 
closed. 

If  the  uterus  has  become  greatly  altered  by  the  growth 
of  a  tumor,  no  description  can  be  given  which  is  applicable 
to  all  cases.  The  abdomen  is  opened  by  a  median  incision 
which  may  have  to  be  prolonged  from  the  symphysis  to 
the  ensiform  process,  and  the  limits  of  the  bladder,  which 
is  apt  to  be  drawn  above  its  usual  position,  are  ascer- 
tained by  a  sound  in  the  urethra  if  necessary.  Adhesions, 
which  may  exist  between  the  tumor  and  any  abdominal 
viscus,  are  carefully  separated  or  divided  between  double 
catgut  ligatures,  and  the  mass  is  gradually  lifted  out  of  the 
belly  by  a  hand  placed  beneath  it,  ascertaining  its  con- 
nections and  the  position  of  the  ovaries,  tubes,  and  the 
broad  ligaments,  and  the  cavity  is  immediately  protected 
by  a  sponge  packing  or  warm  towels. 

It  may  be  possible  to  follow  the  formal  method  of  re- 
moval already  given,  but  otherwise  the  enlarged  uterus 
is  transfixed  below  by  a  couple  of  pins  made  for  the  pur- 
pose with  guarded  points,  and  under  these,  which  prevent 
it  slipping,  an  elastic  tourniquet  or  ecraseur  is  applied,  in- 
37 


578     GEXITO-UBLXARY  ORGANS   OF  THE  FEMALE. 

eluding  both  broad  ligaments,  with  due  regard  for  the  po- 
sition of  the  bladder  ;  frequently  a  smaller  pedicle  can  be 
found  or  must  be  manufactured,  generally  by  dividing  the 
broad  ligaments  in  sections  between  double  catgut  ligatures. 
The  mass  distal  to  the  tourniquet  is  then  excised  and  the 
cervical  canal  disinfected  by  a  drop  of  pure  carbolic  acid. 

If  the  stump  is  to  be  treated  extra-peritoneally,  it  is 
left  in  the  lower  angle  of  the  wound  with  the  tourniquet 
in  place  and  the  pins  resting  on  the  surface  of  the  abdo- 
men ;  the  protective  packing  with  blood  clots,  etc.,  is  re- 
moved ;  and  the  wound  is  closed  in  the  usual  way  around 
the  stump,  with  care  to  secure  peritoneal  apposition,  if 
necessary,  by  sutures  below  the  ligatures. 

Sometimes  the  pins  may  have  to  be  withdrawn  from 
the  stump  and  the  latter  fixed  at  the  level  of  the  parietal 
peritoneum,  where  it  can  be  retained  by  a  couple  of  silk 
sutures  through  the  abdominal  wall  on  each  side  of  the 
wound,  which  is  then  closed  above  and  below  around  a 
packing  placed  in  contact  with   the  stump  and  its  edges. 

If  the  pedicle  is  to  be  treated  by  the  intra-peritoneal 
method,  the  base  of  the  growth  is  cut  in  the  form  of  a  cone 
or  triangle  with  its  apex  in  the  cervical  canal  at  the  level 
of  the  rubber  tourniquet,  and,  after  disinfecting  the  canal 
and  securing  the  open  mouths  of  any  vessels  in  sight,  the 
peritoneal  margins  of  the  stump  are  united  with  catgut, 
the  tourniquet  removed,  and  deep  catgut  sutures  placed  to 
arrest  whatever  bleeding  follows.  The  stump  is  then 
dropped  back  into  the  abdomen,  and  the  latter  cleansed, 
drawing  the  peritoneum  as  Par  as  possible  over  any  ex- 
posed raw  surfaces,  and  the  parietal  wound  is  closed 
annual  drainage  carried  down  to  the  stump,  or  it  is  closed 
tight  without  drainage. 

It  is  always  advisable,  when  practicable,  to  place  inde- 
pendent catgul  ligatures  upon  the  ovarian  arteries.  Liga- 
tures - /'  masse  are  so  apt  to  slip,  and  dangerous  hemor- 
rhage is  bo  frequent  an  accident  after  their  use,  that  if 
the  condition  of  the  patient  permit  the  attempt  should 
always  be  made  to  secure  vessels  <»u  the  cut  surface  of  the 
pedicle  and  then  remove  the  ligature  en  masse. 


ABDOMINAL  HYSTERECTOMY.  579 

Amputation  of  the  Gravid  Uterus.  (Porro's  Opera- 
tion.)— In  a  true  Porro's  operation  the  foetus  is  viable 
and  is  extracted  before  the  uterus  is  excised.  The  abdo- 
men is  opened  and  the  foetus  removed  as  described  for 
laparo-hysterotomy,  except  that  the  longitudinal  direction 
of  the  uterine  incision  is  of  less  consequence.  In  M  tiller's 
modification  the  parietal  incision  is  made  sufficiently  long 
to  permit  the  uterus  to  be  turned  out  of  the  abdomen  be- 
fore the  child  is  removed. 

After  tying  the  cord  the  uterus  is  immediately  lifted 
out  of  the  belly  and  an  elastic  ligature  or  6craseur  is 
thrown  around  the  cervix  and  broad  ligaments.  The 
uterus  with  the  ovaries  and  tubes  is  then  amputated  trans- 
versely about  three-quarters  of  an  inch  above  the  con- 
striction, and  the  stump  is  fastened  in  the  lower  angle  of 
the  wound  by  a  couple  of  pins  transfixing  it  distal  to  the 
ligature  and  resting  on  the  skin  with  the  points  protected. 
The  abdominal  cavity  is  cleansed  and  the  protective 
sponges  are  removed  and  the  wound  is  closed  in  the  usual 
way  around  the  stump,  stitching  the  edges  of  the  peri- 
toneum with  catgut  to  the  uterine  peritoneum  below  the 
constricting  band,  though  this  is  not  always  necessary. 

In  this,  as  in  similar  operations,  it  is  advisable  to  place 
two  dressings  on  the  wound,  the  upper  to  remain  undis- 
turbed, while  the  lower,  covering  the  sloughing  pedicle,  is 
changed  as  often  as  required. 

Vaginal  Hysterectomy. — The  patient  is  catheterized  and 
placed  in  the  lithotomy  position  and  the  external  genitals 
are  thoroughly  disinfected.  The  vagina  is  held  open  by 
broad  retractors  and  the  uterus  is  pulled  down  by  vol- 
sella  forceps  grasping  the  cervix,  while  the  adjoining 
mucous  membrane  is  cut  well  clear  of  the  disease  by  blunt- 
pointed  scissors.  Keeping  close  to  the  uterus  the  dissec- 
tion is  continued  on  its  anterior  and  posterior  surface  by 
the  tip  of  the  finger  and  short  snips  of  the  scissors,  but  at 
the  sides,  after  division  of  the  mucous  membrane,  the  cel- 
lular tissue  is  simply  pushed  up  as  high  as  possible,  or  till 
the  pulsations  of  the  uterine  artery  are  felt.  The  finger 
is  finally  thrust  through  the  utero-vesical  fold  of  peri- 


580     GENITO-UR1NARY  ORGANS  OF  THE  FEMALE. 

toneum,  and  after  cleansing  the  vagina  of  clots  and  debris 
flat  sponges  are  poked  in  around  the  uterus. 

Douglas's  pouch  is  entered  in  the  same  manner,  con- 
trolling the  hemorrhage  from  the  vaginal  wound  by  a  few 
catgut  sutures  through  its  cut  edges,  and  then  the  finger 
is  hooked  over  the  fundus,  pulling  it  down  into  the  pos- 
terior opening  and  thus  bringing  within  reach  the  upper 
border  of  the  broad  ligaments,  which  are  seized  by  long- 
bladed  clamps  and  divided  on  the  uterine  side.  Guided 
by  the  finger,  other  clamps  are  placed  on  the  remaining 
tissues  close  to  the  uterus,  which  is  then  excised. 

Injury  to  the  ureters  is  avoided  by  thorough  separation 
of  the  lower  lateral  cellular  tissue  early  in  the  operation, 
the  ureters  being  pressed  forward  with  the  anterior  layer 
of  the  broad  ligament.  Richelot l  leaves  the  clamps  in 
place  for  twenty-four  to  forty-eight  hours,  but  whenever 
possible  it  is  better  to  secure  with  a  silk  ligature,  at  a 
proper  distance  from  the  clamps,  the  tissues  in  the  grasp 
of  each  before  they  are  severed  from  the  uterus.  Then 
if  the  adnexa  can  be  separated  and  drawn  down  the  ped- 
icle of  each  may  be  secured  with  one  or  more  clamps, 
which  can  be  either  left  in  place  or  the  tissues  in  their 
grasp  can  be  ligated  with  silk  and  the  ovaries  and  tubes 
thus  excised. 

A  rubber  drainage  tube  surrounded  by  iodoform-gauze 
packing  is  placed  in  the  vaginal  wound  and  covered  by  an 
antiseptic  dressing  on  the  vulva. 

AMPUTATION    OF    CERVIX    UTERI. 

Infra- vaginal. — The  cervix  may  be  removed  with  the 
bistoury  <»r  scissors,  the  6craseur,  or  the  galvano-cautery  ; 
flaps  may  be  made  and  united  as  shown  in  Fig.  292.  In 
the  latter  the  cervix  is  split  transversely  from  below  up. 
The  patient  is  placed  in  Sims's  position,  the  speculum  in- 
troduced,  the  cervix  slit  transversely,  and  each  lip  seized 
in  turn  with  forceps,  and  cut  off  as  near  the  vaginal  junc- 
tion ;i-  is  considered  proper.     The  mucous  membrane  of 

1  Uxnals  of  Surgery,  September,  1893,  p.  33. 


AMPUTATION  OF  CERVIX   UTERI. 


581 


the  interior  is  then  drawn  down  and  made  fast  with  silver 
sutures  to  the  outer  edge  of  the  cervix  so  as  to  cover  in 
the  raw  surface.     The  hemorrhage  is  often  very  severe. 

Supra-vaginal. — After  thorough  disinfection  of  the  ex- 
ternal and  internal  genitals  the  patient  is  placed  in  the 
lithotomy  position  and  the  cervix  is  grasped  by  a  volsella 
forceps.     The  mucous  membrane  around  the  cervix  well 
clear  of  the  disease  is  divided  by 
scissors  curved   on   the  flat,  and, 
keeping   close   to  the  uterus,  the 
mucous  membrane  is  dissected  or 
peeled  off  with  the  left  forefinger 
and  the  scissors  in  front  and  be- 
hind, but  at  the  sides,  after  the  first 
incision  of  the  mucous  membrane, 
the    cellular    tissue    between    the 
broad  ligaments  is  simply  pushed 
aside. 


Fig.  292. 


A  B 

Amputation  of  the  cervix  with  double  flaps.  (Simon.)  A.  Sectional  view  show- 
ing lines  of  incision  for  formation  of  flaps  and  method  of  suture.  B.  Front  view 
of  cervix,  operation  complete.     (Pozzi. ) 

When  a  point  is  thus  reached  in  front  and  behind 
where  the  peritoneum  ceases  to  strip  up  readily,  the 
structures  within  the  broad  ligaments  are  seized  by  long- 
bladed  clamps  close  to  the  uterus  and  divided  on  the 
uterine  side.  The  uterus  can  then  probably  be  dragged 
lower,  and,  with  a  sound  in  the  canal,  the  uterine  tissue 
is  cut  obliquely  upward  from  the  exterior  to  the  sound, 


582     GENIT0-UR1NARY  ORGANS  OF  THE  FEMALE. 


while  the  finger  protects  the  surrounding  parts,  and  in  this 
way  the  cervix  and  a  considerable  portion  of  the  body  of 
the  uterus  is  removed.  A  packing  of  iodoform  gauze  is 
placed  in  the  vagina  in  contact  with  the  cut  surface,  and 
the  clamps  are  left  in  place  for  twenty-four  to  forty-eight 
hours,  when  they  can  be  removed  without  disturbing  the 
packing. 

Fig.  293. 


A 

Amputation  of  cervix  by  one  flap  or  excision  of  the  mucosa.  (Schroeder's  opera- 
tion.) A.  Showing  method  of  placing  the  sutures.  (1  and  2  are  those  uniting  the 
commissures.)  I!.  Section  showing  shape  of  incisions  <e  f )  and  (b  c)  line  of  suture. 
C.  Shows  position  of  (laps  after  suturing. 

Schroeder's  Flap  Operation  for  the  Removal  of  Diseased 
Cervical  Mucous  Membrane. — The  cervix  is  split  trans- 
versely from  below  up  to  the  vault  of  the  vagina  and  the 
front  and  back  halves  thus  formed  retracted.  The  mucous 
membrane  and  underlying  tissue  are  then  removed  from 
the  lower  part  of  the  cervical  canal,  as  shown  in  Fig.  293, 
B,  f,  e,  d.  After  this  the  remaining  external  part  of  the 
cervix  (Fig.  293,  B,  X)  is  folded  in  and  sutured  over  the 
raw  surface,  as  illustrated  iu  Fig.  293,  A  and  C.  The 
operation  is  concluded  by  uniting  the  lateral  commissures 
(Fig.  293,  A,  1  and  2). 


INDEX. 


ABDOMEN,  operations  on,  379 
paracentesis  of,  379 
Alexander's  operation,  572 
Amputations,  71 

circular  method,  71 

flap  methods,  73 
Teale,  74,  109 

oval  method,  73 
Anesthesia,  general,  18 

local,  17 

rectal,  20 
Anastomosis,  iutestinal,  390 
Ankle,  amputation  at,  97 

excision,  155 

osteoplastic,  158 
Antrum,  trephining,  213 
Anus,  closure  of  artificial,  401 

excision  of,  449 

fistula,  447 

imperforate,  442 
Aorta,  ligature  of  abdominal,  56 
Appendix,  removal  of  vermiform,  402 
Arm,  amputation,  83 

with  scapula,  SS 
Arteries,  ligature  of,  33 
Arthrectomy  of  hip-joint,  150 
Astragalus,  excision,  157,  194 
Atresia  vaginae,  536 
Axillary  artery,  ligature,  43 


BASSINT,  inguinal  hernia.  434 
Bladder  catheterization,  509 
exstrophy,  507 
puncture,  511 
tumors.  528 
Blepharoplasty.  284 
Blepharorrhaphy,  283 
Brachial  artery, "ligature.  45 

plexus,  225 
Brain,  topography,  200 
abscess,  208 
ventricles,  210 
Breast,  amputation  of,  376 
Broad  ligament,  tumors  of,  569 
Brouchotomy,  357 
Buccal  nerve,  223 

CALCAXECM,  excision,  192 
Canthoplasty,  2>:; 
Carotid,  ligature  of  common,  50 
of  external,  51 
of  internal,  53 
Castration,  480 

Cataract,  depression  or  couching,  310 
division  or  solution,  311 
extraction,  313 
operations  for,  309 


Catheterization,  female  bladder,  533 

male  bladder,  509 
Cervical  glands,  248 

plexus,  226 
Cervix,  amputation  of,  591 

lacerated,  559 

posterior  section,  561 
Cheiloplasty.  253 
Cholecystectomy,  464 
Cholecy stenterostomy .  4G2 
Cholecystostomy,  460 
Chopart's  amputation,  94 
Circumcision,  4S5 
Clavicle,  excision,  181 
Cleft  palate.  338 
Coccyx,  excision,  188 
Colostomy.  397 

left  inguinal,  397 

lumbar,  399 
Colporrhaphy,  55S 
Corelysis,  308 
Cornea,  operations  on,  299 
Craniectomy,  200 
Cranium,  operations  upon,  195 
Crural  nerve,  anterior,  229 
Cystotomy,  supra-pubic,  52:'. 


DORSALIS  pedis,  ligature,  67 
Dressings,  preparation  of,  26 
Dupuytren's  contraction,  247 


EAR,  operations  on,  334 
Ectopic  gestation,  570 
Ectropion,  284 
Elbow,  amputation  at,  SO 

exeision,  131 

of  anchylosed,  137 

reduction  of  dislocated,  139 
Elytrorrhaphy,  557 

posterior,  558 
Euterorrhaphy,  circular,  38S 
Enterostomy,  395 
Entropion,  291 
Epispadias,  487 

Estlauder.  resection  of  ribs,  ISO 
Eustachian  tube,  335 
Excision  of  joints  and  bones.  125 
Exstrophy  of  bladder,  507 
Eye,  operations  on.  299 
Eyeball,  enucleation.  328 
Eyelids,  plastic  operations.  282 


FACE,  plastic  operations.  251 
l'acial  artery,  ligature,  55 
nerve,  225 
Femoral  artery,  ligature,  62 

583 


5S4 


INDEX. 


Femur,  creation  of  false  joint,  150 

excision  of  head,  14G 
of  shaft,  189 

division  of  oeck,  151 

osteotomy,  152,  235 
Fibula,  resection,  190 
Fifth  nerve,  extra-cranial  resection,  21G 

Lntra-cranial  resection,  213 
Fingers,  amputation,  75 

Dupuytren's  contraction,  247 

web,  245 
Fistula  in  auo,  447 

salivary,  355 

urethral,  497 

vesico-vaginal,  549 
Foot,  amputations,  93,  104 

excision  of  bones,  192 
Forearm,  amputation,  79 
Fracture,  operation  for  ununited,  240 
Frajnum  of  tongue,  355 

of  penis,  487 
Frontal  8iuus,  213 


GALL-BLADDER,  operations  on,  4G0 
Gasseriau  ganglion,  213 
Gastro-entcrostomy,  418 
Gastroplicatiou,  415 
Gastrorrhaphy.  414 
Gastrostomy,  407 
Gastrotomy,  411 
Genito-urinary  operations  in  female,  533 

in  male,  480 
Gigli  wire  saw,  197 
Glands,  cervical,  248 
Gluteal  artery,  ligature,  61 
Goitre,  operations  for,  371 
(iritti,  amputation  at  knee,  113 
Guyon,  amputation  of  leg,  107 


HALLUX  valgus,  23G 
Ealsted,  inguinal  hernia,  439 
Harelip,  263 

complicated,  2G7 
double,  266 
Hemorrhage,  arrest,  20 
Hemorrhoids,  I  is 

Hernia,  radical  cure  of  femoral,  i  hi 
Inguinal,  132 
umbilical,  no 
strangulated  femoral,  428 
inguinal,  426 
obturator,  482 
umbilical,  430 
I  terniotomy,  421 
Hip,  amputation  at,  1 18 
I  Up-Joint,  excision,  146 

anchylosis,  150 
Humerus,  resect  Ion,  185 
Hydrocele.  481 
Hypospadias,  192 
Hysterectomy,  abdominal,  576 

vaginal,  579 
ll \  steropexy,  571 


ILIAC  artery,  ligature  of  common,  .'.7 
eternal,  go 
..i  Internal,  59 
I  ii  i Lnate  artery,  ligature,  87 


Inferior  dental  nerve,  220 
Inferior  thyroid  artery,  ligature,  42 
Intestines,  "anastomosis,  390 

operations  on,  383 

suture  of,  385 
Iridectomy,  303 
Iridesis,  307 
Iridotomy,  303 
Iris,  operations  on,  302 
Ischsemia,  artificial,  23 


JAW,  anchylosis  of,  178 
Jejunostomy,  421 


KELOTOMY,  421 
Kidney,  methods  of  exposure,  465 
operations  on,  464 
Knee,  amputation  at,  111 

through  the  condyles,  112 
Garden,  112 
Gritti,  113 
disarticulation,  111 
excision,  153 
Kolpokleisis,  556 
Kraske,  excision  of  rectum,  453 


LACHRYMAL  apparatus,  329 
gland,  removal,  329 
sac  and  duct,  330 
Laminectomy,  242 
Laparo-hysterotomy,  573 
Laparotomy,  380 
Laryngectomy,  364 
Laryngotomy,  357 

cricothyroid,  359    . 

thyroid,  358 
La  ryn  go  tracheotomy,  360 
Leg,  amputation,  105-110 
Ligature  of  arteries,  33 
Lingual  artery,  ligature,  54 

nerve,  224 
Lips,  plastic  operations,  253-267 
Lisfranc's  amputation,  93 
Litholapaxy,  ~>i  l 
Lithotomy,  516 

lateral,  517 

median,  521 

supra-pubic,  523 

in  female,  535 
Liver,  operations  on,  456 

abscess  of,  457 

hydatids  of,  459 


MASTOID  cells,  336 
Maxilla,  inferior,  anehvlosis,  178 
excision,  173 
superior,  excision,  161 
partial,  166,  167,  168 
temporary,  168 

McBll  liny,  ;i(i|p('iiili\,  404 

Inguinal  hernia,  43(j 
Median  oerve,  228 
Medio-tarsal  amputation,  94 
Metacarpal  bone,  amputation,  77 

excision,  1  s7 

Metatarsal  i ,  amputal i'>u,  91 

excision,  195 


INDEX. 


585 


Mikulicz,  excision  of  heel,  158 
Mouth,  operation  on,  337 
Musculospiral  nerve,  229 
Myomectomy,  575 


NASO-PHARYNGEAL  polyp,  168,  1/ 
Neck,  operations  on,  357 
Nephrectomy,  abdominal,  472 

lumbar,  471 
Nephrolithotomy,  469 
Nephropexy,  474 

Nephrotomy,  469 
Neurorrhaphy,  230 
Neurotomy.  215 
Nose,  plastic  operations,  268 


OCCIPITAL  artery,  ligature,  56 
CEsophagotomy,  368 

Olecranon,  suture,  242 

Oophorectomy,  566 

Operation,  preparation  for,  26 

Orbit,  extirpation  of,  329 

Osteotomy,  235 

cuneiform,  for  talipes,  237 
for  hallux  valgus,  236 

Ovariotomy,  564 


PALATE,  cleft,  338 
Patella,  suture  of.  241 
Paracentesis,  abdomen,  379 

thorax, 377 

pericardium,  37S 
Paraphymosis,  487 
Pelvis,  resection  of  bones,  188 
Penis,  amputation  of,  484 
Pericardium,  paracentesis,  378 
Perineorrhaphy,  537 

Hegar,  541 
Perineum,  laceration,  543,  546 
Phalanges,  contraction  of,  246 

excision,  187,  195 
Pharynx,  access  to,  168-173 
Phimosis,  485 
Pharyngotomy,  366 

subhyoid,"357 
Pirogoff,  amputation  at  ankle,  101 
Plastic  operations,  251 

evelids,  282 

face,  251 

lip,  253 

nose,  268 
Popliteal  artery,  ligature,  65 

nerve,  229 
Pott's  fracture,  redaction  of  old,  160 
Preparation  for  operation,  26,  29 
Prostatectomy,  526 
Pterygion,  296 
Pudic  artery,  ligature,  61 
Pylorectomy,  416 
Pyloroplasty,  414 
Pylorus,  stricture  of,  412 


RADIAL  artery,  ligature,  47 
Radius,  excision,  186 
Ranula,  355 
Rectopexy,  446 
Rectum,  excision,  449 


1  Rectum,  operations  on,  441 
prolapse,  444 
Rhinoplasty,  268 
Kibs,  resection,  180 

Round  ligaments,  shortening,  572 
Koux,  amputation  at  ankle,  100 


SALPINGECTOMY,  567 
kj    Salpingo-oophorectomy,  567 
Scapula,  excision,  182 
Seminal  vesicles,  removal,  530 
Sciatic  artery,  ligature,  61 

nerve,  229 
Senn,  amputation  at  hip,  123 
Shoulder,  amputation  at,  83 

excision  of,  128 
Sinus,  frontal,  213 

lateral,  207 
Skin-grafting,  243 
Spinal  accessory  nerve,  226 
Splenectomy,  465 
Sponges,  preparation  of,  26 
Staphylorrhaphy,  338 
Sterilization,  28 
Steruo-eleido-mastoid,"232 
Sternum,  resection  of,  180 
Stomach,  operations  on,  405 
Strabismus,  operation  for,  325 
Subastragaloid  amputation,  96 
Subclavian  artery,  ligature,  39 
Superior  thyroid  artery,  ligature,  41 

maxillary  nerve,  217 
Supraclavicular  region,  35 
Supraorbital  nerve,  215 
Suprapubic  cystotomy,  523 
Sutures,  25 
Symblepharon,  294 
Syme,  amputation  at  ankle,  97 
Symphysiotomy,  574 


TALIPES,  osteotomy,  237 
Tarso-metatarsal  amputation,  93 
Temporal  artery,  ligature  of,  56 
Tendo  Achillis,  231 
Tenorrhaphy,  232 
Tenotomy,  230 
Thiersch,  skin-grafting,  243 
Thigh,  amputation,  115 
Thorax,  operations  on,  376 

paracentesis,  377 
Thyroid  artery,  ligature  of  inferior,  42 
superior,  41 

gland,  operations,  :;71 
Tibia,  resection,  189 
Tibial  artery,  ligature  of  anterior,  65 

posterior,  67 
Tibialis  anticus,  232 

posticus,  231 
Toenail,  ingrown,  247 
Toes,  amputation,  90 
Tongue,  excision,  349 

Kocher,  352 
Tonsils,  amputation,  337 
Torticollis,  227 
Tracheotomy,  361 
Trephining  cranium,  195 

omega  nap,  199 

for  abscess,  208 

for  hemorrhage,  211 


586 


INDEX. 


Trephining  to  reach  cerebellum,  210 

Trichiasis,  297 

Tympanum,  paracentesis,  334 


ULNA,  excision,  186 
Ulnar  artery,  ligature,  49 
nerve,  228 
Uranoplasty,  345 
I'reter,  operations  on,  474 

wounds  of,  477 
(Jretero-ureterostomy,  478 
Urethral  fistula,  497  " 
Urethroplasty,  499 
Urethrorrhaphy,  498 
Urethrotomy,  external,  503,  533 

internal,  502 
Uterus,  amputation  of  gravid,  579 
of  cervix,  580 
laceration  of  cervix,  559 
prolapse  of,  557,  571 
removal  of,  576,  579 


Uterus,  removal  of  mucosa,  582 
tumors  of,  575 


VAGINA,  atresia  of,  536 
narrowing  of,  557 

obliteration  of,  556 

prolapse  of  posterior  wall,  538 
Varicocele,  482 
Ventricles,  puncture  of,  210 
Vermiform  appendix,  402 
Vertebral  artery,  ligature,  43 
Vesico-vaginal  fistula,  549 

creation,  554 
Vesicles,  removal  of  seminal,  530 


WEB-FINGERS,  245 
Wrist,  amputation  at,  78 
excision  of,  140 
Wound,  its  treatment,  29 
Wry-neck,  227 


CATALOGUE  OF  PUBLICATIONS  OF 

LEA    BROTHERS    &    COMPANY, 

706,  708  &  710  Sansoin  St.,  Philadelphia. 
Ill  Fifth  Ave.  (Cor.  18th  St.),  New  York. 
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"index. 

ANATOMY.   _Gray,  p.  11  ;  Treves,  30  ;  Gerriah.  11;  Brockway,  4. 

DICTIONAKlES.     Dunglison,  p.  8  ;  Duane,  8  ;  National,  4 

PHYSICS.     Draper,  p.  8  ;  Robertson,  24  ;  Martin  &  Rockwell,  20. 

PHYSIOLOGY".     Foster,   p.  10;   Chapman,  5;   Schofield,  25;   Collins 
&  Rockwell,  6.  [Luff-,  19  ;  Remsen,  24. 

CHEMISTRY.      Simon,  p.  26  ;  Attfield,  3  ;  Martin  &  Rockwell,  20; 

PHARMACY.     Caspari,  p.  5.  [Bruce,  4  :  Schleif,  25. 

MATERIA   MEDICA.     Culbretb,  p.  6  ;   Maisch,  19  ;  Farquharson,  9  ; 

DISPENSATORY.     National,  p.  21. 

THERAPEUTICS.      Hare,  p.  13  ;  Fothergill,  10  ;  Whitla,  31  ;  Hayem 
&  Hare,  14  ;  Bruce,  4  ;  Schleif,  25  ;  Cushny,  6. 

PRACTICE.     Flint,  p.  9  ;  Loomis  &  Thompson,  19  ;  Malsbary,  20. 

DIAGNOSIS.     Musser,  p.  21 ;  Hare,  12;  Simon,  25;  Herrick,  15;  Hutchi- 
son &  Rainey,  16  ;  Collins,  6. 

CLIMATOLOGY.     Solly,  p.  26  ;  Hayem  &  Hare,  14. 

NERVOUS  DISEASES.     Dercum,  p.  7  ;    Gray,  11  ;  Potts,  23. 

MENTAL  DISEASES.     Clouston,  p.  5  ;  Savage,  24  ;  Folsom,  10. 

BACTERIOLOGY.       Abbott,  p.  2  ;    Vaughan  &  Novy,  30  ;    Senn's 
(Surgical),  25.      Park,  22  ;  Coates,  6.  [Yale,  21. 

HISTOLOGY.     Klein,  p.  17  ;   Schafer's,  25  ;    Dunham,  8  ;  Nichols  & 

PATHOLOGY.    Green,  p.  12;  Gibbes,  10;  Coats,  6;  Nichols  &  Vale,  21 

SURGERY.     Park,  p.  22;  Dennis,  7;  Roberts,  24;  Ashhurst,  3;  Treves, 29; 
Cheyne  &  Burghard,  5  ;  Gallaudet,  10. 

SURGERY— OPERATIVE.     Stimson,  p.  27  ;  Smith,  26  ;  Treves,  29. 

SURGERY— ORTHOPEDIC.     Young,  p.  31  ;  Gibney,  10. 

SURGERY— MINOR.     Wharton,  p.  30.  [BalleDger& 

FRACTURES  and  DISLOCATIONS.    Stimson,  p.  27.  [Wippern,  3. 

OPHTHALMOLOGY.    Nor  ris  &  Oliver,  p.  21;  Nettleship,  21 ;  Juler,17; 

OTOLOGY.  Politzer,  p.  23;  Burnett,  5;  Field,  9;  Bacon,  4. 

LARYNGOLOGY  and  RHINOLOGY.  Coakley.p.  6  ; 

DENTISTRY.     Essig  (Prosthetic),  p.  9  ;  Kirk  (Operative),  17  ;   Ameri- 
can System.  2  ;  Coleman,  6;  Burchard  4. 

URINARY  DISEASES.     Roberts,  p.  24  ;  Black,  4. 

VENEREAL    DISEASES.      Taylor,  p.  28  ;    Hayden,  14  ;    Cornil,  6  ; 

SEXUAL  DISORDERS.     Fuller,  p.  10  ;  Taylor,  29.  [Likes,  19. 

DERMATOLOGY.      Hyde,  p.  16  ;  Jackson,  16  ;   Pye-Smith,  24  ;  Mor- 
ris, 20  ;  Jamieson,  16  ;  Hardaway,  12  ;  Grindon,  12. 

GYNECOLOGY.      American  System,  p.  3  ;    Thomas    &   Mundd,  29 
Emmet,  9  ;  Davenport,  7  ;  May,  20  ;  Dudley,  8  ;  Crockett,  6. 

OBSTETRICS.     American  System,  p.  3  ;   Davis,  7  ;   Parvin,  22  ;   Play- 
fair.  23  ;  King,  17  ;  Jewett,  17  ;  Evans,  9. 

PEDIATRICS.    Smith,  p  26  ;  Thomson,  29  ;  Williams,  31  ;  Tnttle,  30. 

HYGIENE.     Egbert,  p.  9  ;  Richardson,  24  ;  Coates,  6. 

MEDICAL  JURISPRUDENCE.     Taylor,  p.  28. 

QUIZ   SERIES,  POCKET  TEXT-BOOKS   and   MANUALS. 
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ABBOTT  (A.  C).  PRINCIPLES  OF  BACTERIOLOGY:  a  Practical 
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cessfully.  To  those  who  require  a 
condensed  yet  nevertheless  complete 
work  upon  Bacteriology  we  most 
cordially  recommend  it. —  The  Thera- 
peutic Gazette. 


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moderate  amount  of  laboratory  train- 
ing can,   with   a  little   care    as  to 
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AMERICAN  SYSTEM  OP  PRACTICAL  MEDICINE.    A  SYS- 
TEM OF  PRACTICAL  MEDICINE.     In  contributions  by  Various 
American  Authors.    Edited  by  Alfred  L.  Loomis,  M.D.,  LL.D., 
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Every  chapter  is  a  masterpiece  of  cine"    is    a   work  of  which   every 
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"The  American  System  of  Medi-  <  Medical  Journal. 
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PROSTHETIC  DENTISTRY.  Edited  by  Charles  J.  Essig,  M.D., 

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of  Dentistry,  University  of  Pennsylvania,  Philadelphia.    760  pages, 

983  engravings.     Cloth,  $6 ;  leather,  $7.     Net. 

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any  country  where  dentistry  "is  un-  '  which  any  student  can  take  up  dur- 

derstood  as  a  part  of  civilization. —    ing  or  after  college. — Dominion  Den- 

The  International  Dental  Journal.    I  tal  Journal. 

OPERATIVE  DENTISTRY.  Edited  by  Edward  C.  Kirk,  D.D.S., 
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as  in  journalistic  literature,  many  of  manner.    It  is  a  book  that  every 
them  teachers   of  eminence   in   our    progressive  dentist  should  possess, 
colleges      It  shonld  be  included  in  |  and  we  can  heartily  recommend  it 
tin    li«t  of  text-books  set  down   as    to  the  profession. —  The  Ohio  Dental 
mod  useful  to  the  college  student.—     Journal. 
The  Dental  Newt. 


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FOR  STUDENTS  AND  PRACTITIONERS  OF  SURGERY  AND 
MEDICINE.    Edited  by  Roswell  Park,  M.D.     See  page  22. 

ASHHURST  (JOHN,  JR.).  THE  PRINCIPLES  AND  PRACTICE 

OF  SURGERY.     For  the  use  of  Students  and  Practitioners.     Sixth 

and  revised  edition.     In  one  large  and  handsome  octavo  volume  of 

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As  a  masterly  epitome  of  what  has    text-book,  we  do  not  know  its  equal. 

been  said  and  done  in  surgery,  as  a    It   is  the  best  single  text-book   of 

succinct  and  logical  statement  of  the    surgery  that  we  have  yet  seen  in  this 

principles  of  the  subject,  as  a  model    country. — New  York  Post-Graduate. 

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ATTFTEID  (JOHN).  CHEMISTRY;  GENERAL,  MEDICAL  AND 

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or  in  general  practice.    The  modern    a  worthy  companion. —  The  Pittsburg 

scientific  chemical  nomenclature  has    Medical  Review. 

BALLENGER  (W.  L.)  AND  WIPPERN  (A.  G.).  Shortly.  A 
POCKET  TEXT-BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
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BIIiLINGS  (JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONARY. 
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Ohio  Medical  Jour  nal. 

BLOXAM  (C.  Ii.).  CHEMISTRY,  INORGANIC  AND  ORGANIC. 
With  Experiments.  New  American  from  the  fifth  London  edition. 
In  one  handsome  octavo  volume  of  727  pages,  with  292  illustrations. 
Cloth,  $2;  leather,  $3. 

BROCRWAY  (F.  J.).  A  POCKET  TEXT-BOOK  OF  ANAT<  >M  V. 
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trations. Shortly.  Lea's  Scries  of  Pocket  Text-books,  edited  by  Bkrn 
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BRUCE  (J.  MITCHELL).  MATERIA  MEDICA  AND  THERA- 
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PRINCIPLES  OF  TREATMENT.    In  one  octavo  volume.    Pre- 


paring. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth 
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of  1040  pages,  with  727  illustrations.     Cloth,  $6.50 ;  leather,  $7.50. 

BUROHARD  (HENRY H.).  DENTAL  PATHOLOGY  AND  THER- 
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CARTER  (R.  BRUDENELL)  AND  FROST  (W.  ADAMS).  OPH- 
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CASPARI    i  CHARLES    JR.).     A   TREATISE   ON    PHARMACY. 
For  Students  and  Pharmacists.     In  one  handsome  octavo  volume  of 
680  pages,  with  28S  illustrations.     Cloth,  $4.50. 
The  author's  duties  as   Professor    student  who  cannot  understand  must 
of  Theory  and  Practice  of  Pharmacy    be  dull  indeed.    The  book  is  full  of 
in  the  Maryland  College  of  Phar-    new,  clean,  sharp  illustrations,which 
macy,  and  his  contact  with  students    tell  the  story  frequently  at  a  glance, 
made    him    aware    of   their    exact    The  index  is  full  and   accurate. — 
wants  in  the   matter  of  a   manual.    National  Druggist. 
His    work    is   admirable,    and   the 

CHAPMAN  (HENRY  C).     A  TREATISE  ON  HUMAN   PHYSI- 
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its  promise,  whether  as  a  complete    physician. — North  Carolina  Medical 
treatise  for  the  student  or  as  an  ad-    Journal. 

CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIO- 
LOGICAL AND  PATHOLOGICAL  CHEMISTRY.  Octavo,  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  $3.50. 

CHEYNE  fW.  WATSON).    THE    TREATMENT    OF    WOUNDS, 

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Cloth,  $1.25. 

One    will    be    surprised     at    the    need  at  any  moment.     The  sections 

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formation  it  contains;  information    indispensable    to  any   physician. — 

that  the    practitioner  is    likely  to  j  The  Charlotte  Medical  Journal. 

CHEYNE  (W.  W.)  AND  BURGHARD  (F.  F.).  SURGICAL 
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CLELAND  .  JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF 
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CLINICAL  3IANUALS.     See  Series  of  Clinical  Manuals,  page  25. 

CLOUSTON  (THOMAS  S.  |.  CLINICAL  LECTURES  ON  MENTAL 
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COAKLEY  (CORNELIUS  G.).  THE  DIAGNOSIS  AND  TREAT- 
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about  350  pages,  with  many  illustrations.  Shortly.  Lea's  Series  of 
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COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  vol. 
of  829  pages,  with  339  engravings.     Cloth,  $5.50 ;  leather,  $6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY 
AND  PATHOLOGY.  With  Notes  and  Additions  to  adapt  it  to  Amer- 
ican Practice.  By  Thos.  C.  Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one 
handsome  octavo  vol.  of  412  pages,  with  331  engravings.    Cloth,  $3.25. 

COLLINS  (C.  P.).  A  POCKET  TEXT-BOOK  OF  MEDICAL 
DIAGNOSIS.  In  one  handsome  12mo.  volume  of  about  350  pages, 
with  many  illustrations.  Shortly.  Lea 's  Series  of 'Pocket  Text-books, 
edited  by" Bern  B.  Gallaudet,  M.  D.    Seepage  18. 

COLLINS  (H.  D.)  AND  ROCKWELL  (W.  H.).  A  POCKET 
TEXT-BOOK  OF  PHYSIOLOGY.  12mo.  of  316  pages,  with  153 
illustrations.  Just  ready.  Cloth,  $1.50;  flexible  red  leather,  $2.00, 
net.  Lea's  Series  of  Pocket  Text-books,  edited  by  BEEN  B.  GALLAU- 
DET, M.D.    See  page  18. 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES OF  CHILDREN.  Sixth  edition,  revised  and  enlarged.  In 
one  large  8vo.  volume  of  719  pages.     Cloth,  $5.25 ;  leather,  $6.25. 

CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNO- 
SIS AND  TREATMENT.  Translated,  with  Notes  and  Additions,  by 
J.  Henry  C.  Simes,  M.D.  and  J.  William  White,  M.D.  In  one 
8vo.  volume  of  461  pages,  with  84  illustrations.     Cloth,  $3.75. 

CROCKETT  (M.  A.).  A  POCKET  TEXT-BOOK  OF  DISEASE* 
OF  WnMEN.  In  one  handsome  12mo.  volume  of  about  350  pages, 
with  many  illustrations.  Shortly.  Lea's  Series  of  Pocket  Text-books, 
edited  by  BERN   B.  GaLLATTDET,  M.  D.     Seepage  18. 

CROOK  (JAMES  K.)  ON  MINERAL  WATERS  OF  THE 
I 'XI  TED  STATES.   Octavo,  575  pages.   Just  ready.   Cloth,  $3.50,  net. 

CULBRETH  DAVID  M.  R.).  MATERIA  MEDICA  AND  PHAR- 
MACOLOGY. In  one  handsome  octavo  volume  of  812  pages,  with 
445  illustrations.     Cloth,  $4.75. 

CUSHNY    (ARTHUR  R.).   TEXT-BOOK  OF  PHARMACOLOGY. 

Handsome  8vo.,  728  pages,  with  47  illus.  Just  ready.  Cloth,  $3.75,  net. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


DAI/TON  (JOHN  C).    A  TREATISE  ON  HUMAN  PHYSIOLOGY. 

Seventh  edition.     Octavo,   722  pages,  with    252  engravings.     Cloth, 
$5 ;  leather,  $6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.  In 


one  handsome  12mo.  volume  of  293  pages.     Cloth,  $2. 

DAVENPORT  (F.  H.).  DISEASES  OF  WOMEN.  A  Manual  ot 
Gynecology.  For  the  use  of  Students  and  Practitioners.  New 
(3d)  edition.  In  one  handsome  12mo.  volume  of  387  pages,  with  150 
illustrations.     Cloth,  $1.75,  net.    Just  ready. 

DAVIS  (EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  FOR 
STUDENTS  AND  PRACTITIONERS.  In  one  very  handsome 
octavo  volume  of  546  pages,  with  217  engravings  and  30  full-page 
plates  in  colors  and  monochrome.    Cloth,  $5 ;  leather,  $6. 

From  a  practical  standpoint  the  thoroughly  scientific  and  brilliant 
work  is  all  that  could  be  desired.  A    treatise  on  obstetrics.  —Med.  News. 

DAVIS  (P.  H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second 
edition.     In  one  12mo.  volume  of  287  pages.     Cloth,  $1.75. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  octavo 
volume  of  700  pages,  with  300  engravings.     Cloth,  $4. 

DENNIS  (FREDERIC  S.)  AND  BLLLJNGS  (JOHN  S.).  A  SYS- 
TEM OF  SURGERY.  In  contributions  by  American  Authors. 
Complete  work  in  four  very  handsome  octavo  volumes,  containing 
3652  pages,  with  1585  engravings  and  45  full-page  plates  in  colors 
and  monochrome.  Per  volume,  cloth,  $6.00;  leather,  $7.00;  half 
Morocco,  gilt  back  and  top,  $8.50.  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  publishers. 

It  is  worthy  of  the  position  which  i  American  surgery  aud  is  thoroughly 
surgery   has  attained  in  the  great    practical. — Annals  of  Surgery. 
Republic   whence    it  comes.  —  The       No  work  in  English  can  be  con- 
London  Lancet.  sidered  as  the  rival   of  this. —  The 

It  may  be  fairly  said  to  represent  j  American  Journal  of  the  Medical 
the    most     advanced    condition    of  J  Sciences. 

DERCUM  (FRANCIS  X.,  EDITOR).  A  TEXT-BOOK  ON 
NERVOUS  DISEASES.  By  American  Authors.  In  one  handsome 
octavo  volume  of  1054  pages,  with  341  engravings  and  7  colored 
plates.     Cloth,  $6.00;  leather,  $7.00.    Net. 

Representing  the  actual  status  of  The  work  is  representative  of  the 
our  knowledge  of  its  subjects,  and  !  best  methods  of  teaching,  as  devel- 
the  latest  and  most  fully  up-to-date  !  oped  in  the  leading  medical  colleges 
of  any  of  its  class. — Jour,  of  Amer-  of  this  country. — Alienist  and  Neu- 
ican  Med.  Association.  j  rologist. 

The   most  thoroughly  up-to-date        The  best  text-book  in  any  lan- 
treatise  that  we  have  on  this  subject,    guage. — The  Medical  Fortnightly. 
— American  Journal  of  Insanity. 

DE  SCHWEEVITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS. 
Their  Classification,  History,  Symptoms,  Pathology  aud  Treatment. 
Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page 
plates  in  colors.     Limited  edition,  de  luxe  binding,  $4.    Net. 


8       Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


DRAPER  (JOHN  C.j.  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  volume 
of  734  pages,  with  376  engravings.     Cloth,  $4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  A  new  American,  from  the  twelfth  London 
edition,  edited  by  Stanley  Boyd,  F.  R.  C.  S.  In  one  large  octavo 
volume  of  965  pages,  with  373  engravings.     Cloth,  $4 ;  leather,  $5. 

DUANE  (ALEXANDER).  THE  STUDENT'S  DICTIONARY  OF 
MEDICINE  AND  THE  ALLIED  SCIENCES.  New  edition.  Com- 
prising the  Pronunciation,  Derivation  and  Full  Explanation  of  Medi- 
cal Terms,  with  much  Collateral  Descriptive  Matter.  Numerous  Tables, 
etc.  Square  octavo  of  658  pages.  Cloth,  $3.00;  half  leather,  $3.25; 
full  sheep,  $3.75.    Thumb-letter  Index,  50  cents  extra. 

DUDLEY    (E.    C).      THE    PRINCIPLES    AND    PRACTICE    OF 

GYNECOLOGY.     New  (2d)  edition.     Handsome  octavo  of  717  pages, 

with  453  illustrations  in  black  and  colors,  and  8  colored  plates.  Cloth, 

$5.00,  net;  leather, $6.00, net.    Just  ready. 

The   book   can  be   safely    recom- I  tice  of  modern  gynecology. — Inter- 

mended  as  a  complete  and  reliable    national  Medical  Magazine. 

exposition  of  the  principles  and  prac-  I 

DUNCAN  i  J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE 
DISEASES  OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.     Cloth,  $1.50. 

DUNGLISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCI- 
ENCE. Containing  a  full  explanation  of  the  various  subjects  and 
terms  of  Anatomy,  Physiology.  Medical  Chemistry,  Pharmacy,  Phar- 
macology, Therapeutics,  Medicine,  Hygiene,  Dietetics,  Pathology,  Sur- 
gery, Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecol- 
ogy, Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc. 
By  Robley  Dunglison,  M.  D.,  LL.  D.,  late  Professor  of  Institutes 
of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia.  Edited 
by  Richard  J.  DUNGLISON,  A.  M.,  M.  D.  Twenty-first  edition,  thor- 
oughly revised  and  greatly  enlarged  and  improved,  with  the  Pronuncia- 
tion, Accentuation  and  Derivation  of  the  Terms.  With  Appendix. 
In  one  magnificent  imperial  octavo  volume  of  1225  pages.  Cloth,  $7  ; 
leather,  $8  Thumb-letter  Index  for  quick  use,  75  cents  extra. 
The  most  satisfactory  and  authori-    scarcely  be  measured. — Med.  Record. 

tative  guide  to  the  derivation,  defini-        Pronunciation  is  indicated  by  the 

tion  and  pronunciation   of  medical    phonetic  system.  The  definitions  are 

terms.—  The  Charlotte  Med  Journal,    unusually*  clear  and  concise.     The 
Covering  the  entire  field  of  medi-    book  is   wholly   satisfactory. —  Uni- 

cine,    surgery    and    the     collateral    versity  Medical  Magazine. 

sciences,  its  range  of  usefulness  can 

Dl  NHAM  (EDWARD    K.).       MORBID    AND    NORMAL     HIS- 
TOLOGY.    Octavo,  450  pages,with  363  illustrations.  Cloth,  $3.25,  net. 
Tip- 1)' -t  one-volume  text  or  refer- 1  of  published  in  America.—  Virginia 

enee  \»»>\i  on  histology  that  we  know  I  Medical  8t  mi-Monthly. 

EDES  (ROBERT  T.).  TEXT-BOOK  OF  THERAPEUTICS  AND 
MATERIA  MEDICA.  In  one8vo.  volume  of  544  pages.  Cloth, $3.50; 
leather,  $4 .50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for 
Students  and  Practitioners.  In  one  handsome  8vo.  volume  of  576  pages, 
with  148  engravings.     Cloth,  $3;  leather,  $4. 


Lea  Bkothebs  &  Co.,  Philadelphia  and  New  Yoke.       9 

EGBERT  (SENECA).  A  MANUAL  OF  HYGIENE  AND  SANI- 
TATION. In  one  12ino.  volume  of  359  pages,  with  63  illustrations. 
Just  ready.     Cloth,  Net,  $2.25. 


It  is  written  in  plain  language, 
and,  while  primarily  designed  for 
physicians,  it  can  be  studied  with 
profit  by  any  one  of  ordinary  intel- 


ligence. The  writer  has  adapted  it 
to  American  conditions,  and  his 
suggestions  are,  above  all,  practical. 
—  The  NewYork  Medical  Jour  mil. 


ELLIS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY. 
Eighth  edition.  Octavo,  716  pages,  with  249  engravings.  Cloth, 
$4.25 ;  leather,  $5.25. 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  GYNAECOLOGY.  Third  edition.  Octavo,  880  pages,  with 
150  original  engravings.     Cloth,  $5 ;  leather,  $6. 

ERIOHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SUR- 
GERY. Eighth  edition.  In  two  large  octavo  volumes  containing 
2316  pages,  with  984  engravings.     Cloth,  $9  ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  See  American 
Text-Books  of  Dentistry,  page  2. 

EVANS  (DAVID  J.).  A  POCKET  TEXT-BOOK  OF  OBSTETRICS. 
In  one  handsome  12mo.  volume  of  about  300  pages,  with  many  illustra- 
tions. Short/;/.  Lea's  Series  of  Pocket  Text-books,  edited  by  Been  B. 
Gallaudet/M.  D.    See  page  18. 

PARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Fourth  American  from  fourth  English  edition,  revised  by  Frank 
Woodbury,  M.  D.    In  one  12mo.  volume  of  581  pages.    Cloth,  $2.50. 

FD3LD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE 
EAR.  Fourth  edition.  In  one  octavo  volume  of  391  pages,  with  73 
engravings  and  21  colored  plates.      Cloth,  $3.75. 

FLINT  (AUSTIN).    A   TREATISE   ON   THE   PRINCIPLES  AND 

PRACTICE    OF   MEDICINE.     Seventh  edition,  thoroughly  revised 

by  Frederick  P.  Henry,  M.  D.    In  one  large  8vo.  volume  of  1143 

pages,  with  engravings.     Cloth,  $5.00 ;  leather,  $6.00. 

The  work  has  well  earned  its  lead-        The  best  of  American  text-books 

ing  place  in   medical  literature. —    on  Practice. — Amer. Medico-Surgical 

Medical  Record.  Bulletin. 

A   MANUAL   OF   AUSCULTATION  AND  PERCUSSION ;  oi 

the  Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of 
Thoracic  Aneurism.  Fifth  edition,  revised  by  James  C.  Wilson,  M.  D. 
In  one  handsome  12mo.  volume  of  274  pages,  with  12  engravings. 

A    PRACTICAL    TREATISE    ON    TIJE    DIAGNOSIS    AND 

TREATMENT  OF  DISEASES  OF  THE  HEART.  Second  edition 
enlarged.     In  one  octavo  volume  of  550  pages.     Cloth,  $4. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLO- 
RATION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DIS- 
EASES AFFECTING  THE  RESPIRATORY  ORGANS.  Second 
and  revised  edition.     In  one  octavo  volume  of  591  pages.   Cloth,  $4.50. 

MEDICAL  ESSAYS.   In  one  12mo.  vol.  of  210  pages.  Cloth,  $1.38. 

ON  PHTHISIS  :  ITS  MORBID  ANATOMY,  ETIOLOGY,  ETC. 

A  Series  of  Clinical  Lectures.  In  one  8vo.  volume  of  442  pages. 
Cloth,  $3.50. 


10     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


FOLSOM  (C.  P.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S. 
ON  CUSTODY  OF  THE  INSANE.  In  one  8vo.  vol.  of  108  pages. 
Cloth,  $1.50.  With  Clouston  on  Mental  Diseases  (new  edition,  see 
page  6)  $5.00,  net,  for  the  two  works. 

FORMULARY,  POCKET,  see  page  32. 

FOSTER   MICHAEL).    A  TEXT-BOOK  OF  PHYSIOLOGY.    New 

(6th)  and  revised  American  from  the  sixth  English  edition.     In  one 

large  octavo  volume  of  923  pages,  with  257  illustrations.     Cloth,  $4.50 ; 

leather,  $5.50. 

Unquestionably  the  best  book  that        This    single    volume  contains  all 

can  be  placed  in  the  student's  hands,    that  will  be  necessary  in  a  college 

and  as  a  work  of  reference  for  the    course,  and  all   that  the  physician 

busy  physician  it  can   scarcely   be    will  need  as  well. — Dominion  Med. 

excelled. —  The  Phi  la.  Polyclinic.         Monthly. 

FOTHERGILL  (J.  MILNER).  THE  PRACTITIONER'S  HAND- 
BOOK OF  TREATMENT.  Third  edition.  In  one  handsome  octavo 
volume  of  664  pages.     Cloth,  $3.75  ;  leather,  $4.75. 

FOWNES  GEORGEi.  A  MANUAL  OF  ELEMENTARY  CHEM- 
ISTRY (INORGANIC  AND  ORGANIC).  Twelfth  edition.  Em- 
bodying Watts'  Physical  and  Inorganic  Chemistry.  In  one  royal 
12mo.  volume  of  1061  pages,  with  168  engravings,  and  1  colored 
plate.     Cloth,  $2.75 ;  leather,  $3.25. 

FRANKLAND  |  E.)  AND  JAPP  (F.R.).  INORGANIC  CHEMISTRY. 
In  one  handsome  octavo  volume  of  677  pages,  with  51  engravings  and 
2  plates.     Cloth,  $3.75 ;  leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  OR- 
GANS IN  THE  MALE.  In  oue  very  handsome  octavo  volume  of 
238  pages,  with  25  engravings  and  8  full-page  plates.  Cloth,  $2. 
It  is  an  interesting  work,  and  one  i  tive    and   brings    views     of  sound 


which,  in  view  of  the  large  and 
profitable  amount  of  work  done  in 
this  field  of  late  years,  is  timely  and 


pathology  and  rational  treatment  to 
many  cases  of  sexual  disturbance 
whose  treatment  has  been  too  often 


well  needed. — Medical  Fortnightly.  \  fruitless    for     good.  —  Annals    of 
The  book  is  valuable  and  instruc-    Surgery. 

FULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathologv,  Physical  Diagnosis,  Symptoms  and 
Treatment.  From  second  English  edition.  In  one  8vo.  volume  of  475 
pages.     Cloth,  $3.50. 

<.  A  1. 1, A  I  l)i:i  BERN  B.j.  A  POCKET  TEXT-BOOK  ON  SUR- 
GERY, [none  handsome  12mo.  volume  of  about  400  pages,  with  many 
illustrations,  shortly.  Lea's  Series  of  Pocket  Text-books,  edited  by 
Bern  B.  Gallatjdet,  M.  I>.    Bee  page  18. 

GANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  A 
Multum  in  Parvo.  In  one  square  octavo  volume  of  845  pages,  with 
159  engravings.    Cloth,  $3.75. 

GIBBEs  H  BSNBAGB).  PRACTICAL  PATHOLOGY  AND  MORBID 
HISTOLOGY.   Octavo,  314  pages,  with  60  illustrations.   Cloth,  $2.75. 

GD3NEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practi- 
tioners ;ui<1  Students.     In  one  8vo.  vol.  profusely  illus.    Preparing. 


Lea  Brothers  A  Co.,  Philadelphia  and  New  York.      11 


GERRISH  (FREDERIC  H.).  A  TEXT-BOOK  OF  ANATOMY. 
By  American  Authors.  Edited  by  Frederic  H.  Gerrish,  M.  D.  In  one 
imp.  octavo  volume  of  915  pages,  with  950  illustrations  in  black  and 
colors.  Just  ready.  Clth,$6.50;  flexible  waterproof,  $7;  leath.,  $7.50,  net. 

In  this,  the  first  representative  treatise  on  Anatomy  produced  in  America, 
no  effort  or  expense  has  been  spared  to  unite  an  authoritative  text  with  the 
most  successful  anatomical  pictures  which  have  yet  appeared  in  the  world. 

The  editor  has  secured  the  co-operation  of  the  professors  of  anatomy  in 
leading  medical  colleges,  and  with  them  has  prepared  a  text  conspicuous 
for  its  simplicity,  unity  and  judicious  selection  of  such  anatomical  facts  as 
bear  on  physiology,  surgery  and  internal  medicine  in  the  most  compre- 
hensive sense  of  those  terms.  The  authors  have  endeavored  to  make  a 
book  which  shall  stand  in  the  place  of  a  living  teacher  to  the  student,  and 
which  shall  be  of  actual  service  to  the  practitioner  in  his  clinical  work, 
emphasizing  the  most  important  subjects,  clarifying  obscurities,  helping 
most  in  the  parts  most  difficult  to  learn,  and  illustrating  everything  by  all 
available  methods. 

GOULD  (A.  PEARCE).      SURGICAL  DIAGNOSIS.     In  one  12mo. 

vol.  of  589  pages.     Cloth,  $2.  See  Student's  Series  of  3fanuals,  p.  27. 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 
New  and  thoroughly  revised  American  edition,  much  enlarged  in  text, 
and  in  engravings  in  black  and  colors.  In  one  imperial  octavo  volume 
of  1239  pages,  with  772  large  and  elaborate  engravings  on  wood.  Price 
of  edition  with  illustrations  in  colors  :  cloth,  $7  ;  leather,  $8.  Price 
of  edition  with  illustrations  in  black :  cloth,  $6  ;  leather,  $7. 

This  is  the  best  single  volume 
upon  Anatomy  in  the  English 
language.—  University  Medical  Mag- 
azine. 


Gray' s  Anatomy  affords  the  student 
more  satisfaction  than  any  other 
treatise  with  which  we  are  familiar. 
— Buffalo  Med.  Journal. 

The  most  largely  used  anatomical 
text-book  published  in  the  English 
language. — Annals  of  Surgery. 

Particular  stress  is  laid  upon  the 
practical  side  of  anatomical  teach- 


ing, and  especially  the  Surgical 
Anatomy. — Chicago  Med.  Recorder. 

Holds  first  place  in  the  esteem  of 
both  teachers  and  students. — The 
Brooklyn  3/edical  Journal. 

The  foremost  of  all  medical  text- 
books.— Medical  Fortn  ightiy. 

Gray's  Anatomy  should  be  the 
first  work  which  a  medical  student 
should  purchase,  nor  should  he  be 
without  a  copy  throughout  his  pro- 
fessional career. — Pittsburg  Medical 
Review. 


GRAY  (LANDON  CARTER).  A  TREATISE  ON  NERVOUS  AND 
MENTAL  DISEASES.  For  Students  and  Practitioners  of  Medicine. 
New  (2d)  edition.  In  one  handsome  octavo  volume  of  728  pages,  with 
172  engravings  and  3  colored  plates.     Cloth,  $4.75 ;   leather,  $5.75. 


An  up-to-date  text-book  upon 
nervous  and  mental  diseases  com- 
bined. A  well-written,  terse,  ex- 
plicit, and  authoritative  volume 
treating  of  both  subjects  is  a  step  in 
the  direction  of  popular  demand. — 
The  Chicago  Clinical  Review. 

The   descriptions  of  the  various 


diseases  are  accui-ate  and  the  symp- 
toms and  differential  diagnosis  are 
set  before  the  student  in  such  a  way 
as  to  be  readily  comprehended.  The 
author's  long  experience  renders  his 
views  on  therapeutics  of  great  value. 
— The  Journal  of  Nervous  and  Men- 
tal Disease. 


12      Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

GREEN  <T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY 
AND  MORBID  ANATOMY.  New  (8th)  American  from  the  eighth 
London  edition.  In  one  handsome  octavo  volume  of  582  pages,  with 
216  engravings  and  a  colored  plate.     Cloth,  $2.50,   net.    Just  ready. 

A  work  that  is  the  text-book  of   as    to  give    to  each   detail   of  text 
probably  four-fifths  of  all  the  stu-    sufficient  explanation.    The  work  is 


an  essential    to   the    practitioner- 
whether  as  surgeon  or  physician.     It 
is  the  best  of  up-to-date  text-books. 
—  Virginia  Med.  Monthly. 


dents  of  pathology  in  the  United 
States  and  Great  Britain. — The 
American  Practitioner  and  News. 

It  is  fully  up-to-date  in  the  record 
of  fact,  and  so  profusely  illustrated 

GREENE  (WILLIAM  H.).  A  MANUAL  OF  MEDICAL  CHEM- 
ISTRY. For  the  Use  of  Students.  Based  upon  Bowman's  Medical 
Chemistry.     In  one  12mo.  vol.  of  310  pages,  with  74  illus.   Cloth,  $1.75. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES, INJURIES  AND  MALFORMATIONS  OF  THE  URINARY 
BLADDER,  THE  PROSTATE  GLAND  AND  THE  URETHRA. 
Third  edition.    Octavo,  574  pages,  with  170  illustrations    Cloth,  $4.50. 

GRENDON  (JOSEPH).  A  POCKET  TEXT-BOOK  OF  SKIN 
DISEASES.  In  one  handsome  12mo.  volume  of  350  pages,  with 
many  illustrations.  Short/;/.  Lea's  Series  of  Pocket  Text-books,  edited 
by  BERN  IJ.  Gallatjdet,  M.  D.     See  page  18. 

HARERSHON  <S.  O.).  ON  THE  DISEASES  OF  THE  ABDOMEN 
Second  American  from  the  third  English  edition.  In  one  octavo  vol- 
ume of  554  pages,  with  11  engravings.     Cloth,  $3.50. 

HALL  (WLNFIELD  S.j.  TEXT-BOOK  OF  PHYSIOLOGY.  Octavo 
of  672  pages,  with  343  engravings,  and  6  full  page  colored  plates.  Just 
ready.    Cloth,  $4.00;  leather,  $5.00,  net. 

HAMILTON  (ALLAN  MCLANE).  NERVOUS  DISEASES,  THEIR 
DESCRIPTION  AND  TREATMENT.  Second  and  revised  edition. 
In  one  octavo  volume  of  598  pages,  with  72  engravings.     Cloth,  $4. 

HARD  A  WAY  ( W.  A. ).     MANUAL  OF  SKIN  DISEASES.     New  (2d) 
edition.    In  one  12mo.  volume  of  ">oO  pages,  with  40  illustrations  and 
2  plates.    Cloth,  $2.25,  net.    Just  ready. 
The  best  of  all  the  .-mall  books  to    day  clinical  experience.     His  great 
recommend  to  students  and   practi-    strength  is  in  diagnosis, descriptions 
tioners.     Probably   do  one   of  our    of  Lesions  and   especially   in   treat- 
dermatologists  ha- had  a  wider  every-    ment. — Indiana  Medical  Journal. 

HARE  (HOBART  AMORY).     PRACTICAL    DIAGNOSIS.     THE 
I  8E  I  >I"  SYMPTOMS  IN  THE  DIAGNOSIS  OF  DISEASE.    New 
lili)  edition.   In  one  octavo  volume  of  623  pages,  with  20.">  engravings 
and  11  full-page  colored  plates.     Cloth,  $5.00,  net.    Just  ready. 
It  is  unique  in  many  respects,  and    he  will    become  a  better  diagnosti- 
the  author  has    introduced  radical    cian.   This  is  a  companion  to  /Vac- 
changes  which  will  be  welcomed  by    Heal    Therapeutics,    by    the    same 
all.     Anyone  who  reads   this  book    author,  and  it  is  difficult  to  conceive 
will  become  a  more  acute  observer,    of  any  two  works  of  greater  practical 
will  pay  more  attention  to  the  simple    utility. — Medical  Review. 
yet  indicative  signs  of  disease,  and 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.      13 

HARE  (HOBART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL 
THERAPEUTICS,  with  Special  Reference  to  the  Application  of  Reme- 
dial Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  With  articles  on  various  subjects  by  well-known  specialists. 
New  (7th)  and  revised  edition.  In  one  octavo  volume  of  776  pages. 
Cloth,  $3.75,  net;  leather,  $4.50,  net. 

Its  classifications  are  inimitable,  it  can  be  readily  used  in  connection 

and  the  readiness  with   which  any-  with    Hare's    Practical    Diagnosis. 

thing  can  be  found  is  the  most  won-  For  the   needs   of  the   student  and 

derful  achievement  of  the  art  of  in-  general  practitiouer  it  has  no  equal, 

dexing.     This  edition    takes  in    all  — Medical  Sentinel. 

the    latest    discovered     remedies. —  The  best  planned  therapeutic  work 

The  St.  Louis  Clinique.  of    the    century. — American     Prac- 

The  great  value  of  the   work  lies  titioner  and  News. 

in  the  fact  that  precise  indications  It  is  a  book  precisely  adapted  to 
for    administration    are   given.      A  i  the  needs  of  the  busy  practitioner, 

complete   index     of     diseases     and  who  can  rely  upon  finding  exactly 

remedies  makes  it  an  easy  reference  what  he  needs. —  The  National  Med- 

work.     It  has  been  arranged  so  that  ical  Review. 

HARE  (HOBART  AMORY)  ON  THE  MEDICAL  COMPLICA- 
TIONS AND  SEQUEL.E  OF  TYPHOID  FEVER.  Octavo,  276 
pages,  21  engravings  and  two  full-page  plates.  Just  ready.  Cloth, 
$2.  to,  net. 

A  very  valuable  production.    One    read  with   great  profit. —  Cleveland 
of  the  very  best   products  of   Dr.    Journal  of  Medicine. 
Hare  and  one  that  eveiy  man  can 

HARE  (HOBART  AMORY,  EDITOR).  A  SYSTEM  OF  PRAC- 
TICAL THERAPEUTICS.  In  a  series  of  contributions  by  eminent 
practitioners.  In  four  large  octavo  volumes  comprising  about  4500 
pages,with  about  550  engravings.  Vol.  IV.,  just  ready.  For  sale  by  sub- 
scription only.  Full  prospectus  free  on  application  to  the  Publishers. 
Regular  price,  Vol.  IV.,  cloth,  $6 ;  leather,  $7 ;  half  Russia,  $8. 
Price  Vol.  IV.  to  former  or  new  subscribers  to  complete  work,  cloth, 
$5  ;  leather,  $6  ;  half  Russia,  $7.  Complete  work,  cloth,  $20 ;  leather, 
$24 ;  half  Russia,  $28. 

The  great  value  of  Hare's  System  of  Practical  Therapeutics  has  led  to  a 
widespread  demand  for  a  new  volume  to  represent  advances  in  treatment 
made  since  the  publication  of  the  first  three.  More  than  fulfilling  this 
request  the  Editor  has  secured  contributions  from  practically  a  new  corps 
of  equally  eminent  authors,  so  that  entirely  fresh  and  original  matter  is 
ensured.  The  plan  of  the  work,  which  proved  so  successful,  has  been  fol- 
lowed in  this  new  volume,  which  will  be  found  to  present  the  latest  devel- 
opments and  applications  of  this  most  practical  branch  of  the  medical  art. 
The  entire  System  is  an  unrivalled  encyclopaedia  on  the  practical  parts  of 
medicine,  and  merits  the  great  success  it  has  won  for  that  reason. 


14     Lea  Bbothebs  &  Co.,  Philadelphia  and  New  Yobk. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
volume,  669  pages,  with  144  engravings.     Cloth,  $2.75 . 

A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.    In  one 


12mo.  volume  of  310  pages,  with  220  engravings.     Cloth,  $1.75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.    Comprising 

Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Prac- 
tice of  Medicine,  Surgery  and  Obstetrics.  Second  edition.  In  one  royal 
12mo.  vol.  of  1028  pages,  with  477  illus.     Cloth,  $4.25 ;  leather,  $5. 

HAYDEN  (  JAMES  R.).  A  MANUAL  OF  VENEREAL  DISEASES. 
New  (2d)  edition.  In  one  12mo.  volume  of  304  pages,  with  54  en- 
gravings.    Cloth,  $1.50,  net. 

It  is  practical,  concise,  definite  ticularly  thorough,  and  may  be 
and  of  sufficient  fulness  to  be  satis-  relied  upon  as  a  guide  in  the  man- 
factory.—  Ch tea go   Clinical  Review,  agement  of  this  class  of  diseases.— 

This  work  gives  all  of  the  prac-  Northwestern  Lancet. 

tically  essential  information    about  It  is  well  written,  up  to  date,  and 

the  three   venereal    diseases,    gon-  will  be  found  very    useful. — Inter- 

orrboea,  the  chancroid  and  syphilis,  national  Medical  Magazine. 
In  diagnosis  and  treatment  it  is  par- 

HAYEM  GEORGES)  AND  HARE  H.  A).  PHYSICAL  AND 
NATURAL  THERAPEUTICS.  The  Remedial  Use  of  Heat,  Elec- 
tricity, Modifications  of  Atmospheric  Pressure,  Climates  and  Mineral 
Wate'rs.  Edited  by  Prof.  H.  A.  Hare,  M.  D.  In  one  octavo  volume 
of  414  pages,with  113  engravings.     Cloth,  $3. 

This  well-timed  up-to-date  volume  recognition.        Within    this     large 

is  particularlv  adapted    to  the  re-  range    of     applicability,     physical 

quirements  of  the    general    practi-  agencies  when  compared  with  drugs 

tioner.      The    section    on     mineral  are  more  direct  and  simple  in  their 

waters  is  most  scientific  and  prac-  results.     Medical  literature  has  long 

tical.     Some  200  pages  are  given  up  been  rich  in  treatises  upon  medical 

to  electricity  and  evidently  embody  agents,    but  an  authoritative  work 

tin   latest  scientific  information  on  upon    the    other    gnat    branch    of 

the  subject.     Altogether  this  work  therapeutics  has  until  now  been  a 

is  the  cfearestand  most  practical  aid  desideratum.  The  section  on  climate, 

to  the  studv  of  nature's  therapeutics  rewritten    by    Prof.    Hare,  will,  for 

that  has  yet  come  under  our  obser  the  first  time,  place   the  abundant 

vation.—  The  Medical   Fortnightly,  resources  of  our  country  at  the  in- 

For  manv  diseases  the  most  potent  telligent     command    of    American 

remedies  lie  outside  of  the  materia  practitioners. —  The    Kansas     City 

medica,  a  fact  yearly  receiving  wider  Medical  Index. 

HERMAN  (G.  ERNEST).  FIRST  LINES  IN  MIDWIFERY.  In 
one  12mo.  vol.  of  198  pages,  with  80  engravings.  Cloth,  $1.25.  See 
Student's  Series  of  Manuals,  page  27. 

HERMANN  L.i.  EXPERIMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  Rohkrt  Mkauk  Smith,  M.  D.  In  one  12mo. 
volume  of  199  pages,  with  32  engraving's.     Cloth,  $1.50. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     15 


HERRICK  (JAMES  B.).  A  HANDBOOK  OF  DIAGNOSIS.  In 
one  handsome  12mo.  volume  of  429  pages,  with  80  engravings  and  2 
colored  plates.    Cloth,  $2.50. 


Excellently  arranged,  practical, 
concise,  up-to-date,  and  eminently 
well  fitted  for  the  use  of  the  prac- 
titioner as  well  as  of  the  student. — 
Chicago  Med.  Recorder. 

This  volume  accomplishes  its  ob- 
jects more  thoroughly  and  com- 
pletely than  any  similar  work  yet 
published.     Each  section  devoted  to 


microscopical  examination  to  be  em- 
ployed in  each  class.  The  technique 
of  blood  examination, including  color 
analysis,  is  very  clearly  stated. 
Uranalysis  receives  adequate  space 
and  care. — New  York  Med.  Journal. 
We  commend  the  book  not  only  to 
the  undergraduate,  but  also  to  the 
physician  who  desires  a  ready  means 


diseases  of  special  systems  is  pre- ,  of  refreshing  his  knowledge  of  diag 
ceded  with  an  exposition  of  the  l  nosis  in  the  exigencies  of  professional 
methods  of  physical,  chemical  and    life. — Memphis  Medical  Monthly. 

HILL  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS 
DISORDERS.     In  one  8vo.  volume  of  479  pages.     Cloth,  $3.25. 

HILLIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES. 
Second  edition.  In  one  royal  12mo.  volume  of  353  pages,  with  two 
plates.     Cloth,  $2.25. 

HIRST  (BARTON  C.)  AND  PBERSOL  (GEORGE  A.).  HUMAN 

MONSTROSITIES.  Magnificent  folio,  containing  220  pages  of  text 
and  illustrated  with  123  engravings  and  39  large  photographic  plates 
from  nature.  In  four  parts,  price  each,  $5.  Limited  edition.  For  sale 
by  subscription  only. 

HOBLYN  (RICHARD  D.).  A  DICTIONARY  OF  THE  TERMS 
USED  IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES. 
In  one  12mo.  volume  of  520  double-columned  pages.  Cloth,  $1.50 ; 
leather,  $2. 

HODGE  (HUGH  L.).  ON  DISEASES  PECULIAR  TO  WOMEN 
INCLUDING  DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.     In  one  8vo.  vol.  of  519  pp.,  with  illus.     Cloth,  $4.50 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.). 

A  MANUAL  OF  CHEMICAL  ANALYSIS,  as  Applied  to  the 
Examination  of  Medicinal  Chemicals  and  their  Preparations.  Third 
edition,  entirely  rewritten  and  much  enlarged.  In  one  handsome  octavo 
volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Prin- 
ciples and  Practice.  A  new  American  from  the  fifth  English  edition. 
Edited  by  T.  Pickering  Pick,  F.R.C.S.  In  one  handsome  octavo  vol- 
ume of  10084'pages,  with  428  engravings.     Cloth,  $6  ;  leather,  $7. 

A  SYSTEM  OF  SURGERY.  With  notes  and  additions  by  various 

American  authors.  Edited  by  John  H.  Packard,  M.  D.  In  three 
very  handsome  8vo.  volumes  containing  3137  double-columned  pages, 
with  979  engravings  and  13  lithographic  plates.  Per  volume,  cloth,  $6  ; 
leather,  $7  ;  half  Russia,  $7.50.     For  sale  by  subscription  only. 


16     Lea  Beothees  &  Co.,  Philadelphia  and  New  Yoek. 


HORNER  (WILLIAM  E.).  SPECIAL  ANATOMY  AND  HIS- 
TOLOGY. Eighth  edition,  revised  and  modified.  In  two  large  8vo. 
volumes  of  1007  pages,  containing  320  engravings.    Cloth,  $6. 


HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER, 
octavo  volume  of  308  pages.    Cloth,  $2.50. 


In  one 


HUTCHISON  (ROBERT)  AND  RAINY  (HARRY).  CLINICAL 
METHODS.  A  GUIDE  TO  THE  PRACTICAL  STUDY  OF 
MEDICINE.  In  one  12mo.  volume  of  562  pages,  with  137  engrav- 
ings and  8  colored  plates.    Cloth,  $3.00. 

A  comprehensive,   clear  and   re-    medical   knowledge  which    receive 
markablyup-to-date  guide  to  clinical    recognition,     we    mention    Widal's 


diagnosis.  The  illustrations  are 
plentiful  and  excellent.  As  exam- 
ples of  the  more  recent  additions  to 


test  for  typhoid  and  the  Neuron 
theory  of  the  nervous  system. — 
Montreal  Medical  Journal. 


HUTCHINSON  (JONATHAN).  SYPHILIS.  In  one  pocket-size  12mo. 
volume  of  542  pages,  with  8  chromo-lithographic  plates.  Cloth,  $2.25. 
See  Series  of  Clinical  Manuals,  p.  25. 


HYDE  ( JAMES  NEVINS).  A  PRACTICAL  TREATISE  ON  DIS- 
EASES OF  THE  SKIN.  New  (4th)  edition,  thoroughly  revised. 
In  one  octavo  volume  of  815  pages,  with  110  engravings  and  12  full- 
page  plates,  4  of  which  are  colored.     Cloth,  $5.25;  leather,  $6.25. 


This  edition  has  been  carefully  re- 
vised, and  every  real  advance  has 
been  recognized.  The  work  answers 
the  needs  of  the  general  practitioner, 
the  specialist,  and  the  student. —  The 
Ohio  Med.  Jour. 

A  treatise  of  exceptional  merit 
characterized  by  conscientious  care 
and  scientific  accuracy. — Buffalo 
Med.  Journal. 

A  complete  exposition  of  our 
knowledge  of  cutaneous  medicine  as 
it  exists  to-day.  The  teaching  in- 
culcated throughout  is  sound  as  well 


as  practical. —  The  American  Jour- 
nal of  the  Medical  Sciences. 

It  is  the  best  one-volume  work 
that  we  know.  The  student  who 
gets  this  book  will  find  it  a  useful 
investment,  as  it  will  well  serve  him 
when  he  goes  into  practice. —  Vir- 
ginia Medical  Semi-Monthly. 

A  full  and  thoroughly  modern 
text-book  on  dermatology.  —  The 
Pittsburg  Medical  Review. 

It  is  the  most  practical  hand- 
book on  dermatology  with  which  we 
are  acquainted. — The  Chicago  Med- 
ical Recorder. 


JACKSON  (GEORGE   THOMAS).    THE   READY-REFERENCE 

HANDBOOK  OF  DISEASES  OF  THE  SKIN.  New  (3d)  edition. 
In  one  12mo.  volume  of  637  pages,  with  75  illustrations  and  a  colored 
plate.    Just  ready.     Cloth,  $2.50,  net. 


h-  :i  student's  manual,  it  may  be 
considered  beyond  criticism.  The 
book  is  singularly  full. — St.  Lowit 
\fedical  "ml  Surgical  Journal. 


Without  doubt  forms  one  of  the 
best  guides  for  the  beginner  in  der- 
matology that  is  to  be  found  in  the 
English  language. — Medicine. 


JAM1ESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third 
edition.  In  one  octavo  volume  of  656  pages,  with  1  engraving  and  9 
double-page  chromo-lithographic  plates.    Cloth,  $6. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     17 

JEWETT  (CHARLES).  ESSENTIALS  OF  OBSTETRICS.    In  one 
12mo.  volume  of  356  pages,  with  80  engravings  and  3  colored  plates. 
Cloth,  $2.25.    Just  ready. 
An  exceedingly  useful  manual  for    ing  it  in  attractive  and  easily  tangi- 

student  and  practitioner.    The  au-  '  ble  form.    The  book  is  well   illus- 

thor  has  succeeded  unusually  well    trated  throughout. — Nashville  Jour. 

in  condensing  the  text  and  in  arrang-    of  Medicine  and  Surgery. 

THE  PRACTICE  OF  OBSTETRICS.     By   American    Authors. 

One  large  octavo  volume  of  763  pages,  with  441  engravings  in  black 

and    colors,  and    22  full-page  colored    plates.     Just   ready.    Cloth, 

$5.00,  net ;  leather,  $6.00,  net. 

A  clear  and  practical  treatise  upon  I  the  book    abounds.     The  work  is 

obstetrics  by  well-known  teachers  of   sure  to  be  popular    with    medical 

the  subject.     A  special    feature  of   students,  as  well  as  being  of  extreme 

this  work  would   seem    to    be   the    value  to    the    practitioner.  —  The 

excellent  illustrations    with  which  |  Medical  Age. 

JONES  (C.  HANDFIELD).  CLINICAL  OBSERVATIONS  ON 
FUNCTIONAL  NERVOUS  DISORDERS.  Second  American  edi- 
tion.    In  one  octavo  volume  of  340  pages.     Cloth,  $3.25. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 
AND  PRACTICE.      Second  edition.  In  one  octavo  volume  of  549 

Sages,  with  201  engravings,  17  chromo-lithographic  plates,  test-types  of 
aeger  and  Snellen,  and  Holmgren's  Color-Blindness  Test.     Cloth, 
$5.50 ;  leather,  $6.50. 
The  volume  is  particularly  rich  in    color  blindness,   etc.    The    sections 
matter  of  practical  value,   such   as    devoted  to  treatment  are  singularly 
directions    for    diagnosing,    use    of  j  full  and  concise. — Medical  Age. 
instruments,  testing  for  glasses,  for  I 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Seventh  edition. 
In  one  12mo.  volume  of  573  pages,  with  223  illustrations.  Cloth, 
$2.50. 

From  first  to  finish  it  is  thoroughly  cyclopedias.  The  well-arranged 
practical,  concise  in  expression,  well  index  renders  the  book  useful  to 
illustrated,  and  includes  a  statement  the  practitioner  who  is  in  haste  to 
of  nearly  every  fact  of  importance  refresh  his  memory.  ■ —  Virginia 
discussed  in    obstetric    treatises  or  |  Medical  Semi-Monthly. 

KIRK   (EDWARD    C).      OPERATIVE  DENTISTRY.     Handsome 
octavo  of  700  pages,  with  751  illustrations.   Just  ready.    See  American 
Text-Books  of  Dentistry,  page  2. 
We  have  only  the  highest  praise    tempted.     We  can  heartily  recom- 
for  this  valuable  work.   It  is  replete    mend    it    to    the    profession. — The 
in  every  particular,  and  surpasses    Ohio  Dental  Journal. 
anything  of  the  kind  heretofore  at-  I 

KLEIN  (E.).    ELEMENTS  OF  HISTOLOGY.    New  (5th)  edition.   In 
one  12mo.   volume  of  506  pages,  with  296  engravings.     Just  ready. 
Cloth,  $2.00,  net.     See  Student's  Series  of  Manuals,  page  27. 
It  is  the  most  complete  and  con-        This  work  deservedly  occupies  a 

cise  work  of  the  kind  that  has  yet    first  place  as  a  text-book  on   his- 

emanated  from  the  press. —  The  Med-    tology. — Canadian  Practitioner. 

ical  Age. 


18     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

LANDIS  (HENRY  G.).  THE  MANAGEMENT  OF  LABOR.  In  one 

handsome  12mo.  volume  of  329  pages,  with  28  illus.    Cloth,  $1.75. 

L<A  ROCHE  CR.).  YELLOW  FEVER.  In  two  8vo.  volumes  of  1468 
pages.    Cloth,  $7. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY- 
BOOK  OF  OPHTHALMIC  SURGERY.  Second  edition.  In  one 
octavo  volume  of  227  pages,  with  66  engravings.     Cloth,  $2.75. 

LEA'S  SERIES  OP  POCKET  TEXT-BOOKS,  edited  by  Bern 
B.  Gallatjdet,  M.  D.  Covering  the  entire  field  of  Medicine  in  a 
series  of  16  very  handsome  12mo.  volumes  of  350-450  pages  each, 
profusely  illustrated.  Compendious,  clear,  trustworthy  and  modern. 
The  following  volumes  constitute  the  series. 

Coaxes'  Bacteriology  and  Hygiene.  Brockway's  Anatomy.  Collins 
and  Rockwell's  Physiology.  Martin  and  Rockwell's  Chemistry 
and  Physics.  NiciioLS  and  Vale's  Histology  and  Pathology. 
Schleif'S  Materia  Medica,  Therapeutics,  Medical  Latin,  etc.  Mals- 
bary's  Practice  of  Medicine.  Collins'  Diagnosis.  Potts'  Nervous 
and  Mental  Diseases.  Gallaudet'S  Surgery.  Likes'  Genito- 
urinary and  Venereal  Diseases.  Grinpon'S  Dermatology.  Ballen- 
GER  and  Wippeex's  Diseases  of  the  Eye,  Ear,  Throat  and  Nose. 
Evans'  Obstetrics.  Crockett's  Gynecology.  Tuttle's  Diseases  oi 
Children. 

For  separate  notices  see  under  various  authors'  names. 

LEA  (HENRY  C).  A  HISTORY  OF  AURICULAR  CONFESSION 
AND  INDULGENCES  IN  THE  LATIN  CHURCH.  In  three 
octavo  volumes  of  about  500  pages  each.     Per  volume,  cloth,  $3.00. 

CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF  SPAIN ; 

CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMIN  ATI  - 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  DE  LA  GUARDIA; 
BRIANDA   DE   BARDAXI.     12mo.,  522  pages.     Cloth,  $2.50. 

FORMULARY  OF  THE   PAPAL  PENITENTIARY.    In  one 

octavo  volume  of  221  pages,  with  frontispiece.    Cloth,  $2.50. 

SUPERSTITION   AND  FORCE ;  ESSAYS  ON  THE  WAGER 

OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  Fourth  edition,  thoroughly  revised.  In  one  hand- 
some royal  12mo.  volume  of  629  pages.     Cloth,  $2.75. 

STUDIES  IN  CHURCH  HISTORY.    The  Rise  of  the  Temporal 

Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one 
handsome  12mo.  volume  of  605  pages.     Cloth,  $2.50. 


AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 

IN  THE  CHRISTIAN   CHURCH.     Second  edition.     In  one  hand- 
some octavo  volume  of  685  pages.    Cloth,  $4.50. 

LEHMANN  (C.  G.).     A  MANUAL  OF  CHEMICAL  PHYSIOLOGY. 
In  one  8vo.  volume  of  327  pages,  with  41  engravings.     Cloth,  $2.25. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     19 

LTKES  (SYLVAN  H.).  A  POCKET  TEXT-BOOK  OF  GENITO- 
URINARY AND  VENEREAL  DISEASES.  In  one  handsome 
12rao.  volume  of  about  350  pages,  with  many  illustrations.  Shortly. 
Lea's  Series  of  Pocket  Text-books,  edited  by  Bern  B.  Gallattdet, 
M.  D.     See  page  18. 

LOOMIS     (ALFRED    L.)    AND    THOMPSON    (W.    GDLiMAN, 

EDITORS).      A  SYSTEM   OF    PRACTICAL    MEDICINE.      In 

Contributions  by  Various  American  Authors.  In  four  very  hand- 
some octavo  volumes  of  about  900  pages  each,  fully  illustrated  in 
in  black  and  colors.  Complete  work  now  ready.  Per  volume,  cloth, 
$5 ;  leather,  $6 ;  half  Morocco,  $7.  For  sale  by  subscription  only. 
Full  prospectus  free  on  application  to  the  Publishers.  See  American 
System  of  Practical  Medicine,  page  2. 

LUFF  (ARTHUR  P.).     MANUAL  OF  CHEMISTRY,  for  the  use  of 

Students  of  Medicine.  In  one  12mo.  volume  of  522  pages,  with  36 
engravings.     Cloth,  $2.     See  Student's  Series  of  Manuals,  page  27. 

LYMAN  (HENRY  M.).     THE  PRACTICE  OF  MEDICINE.    In  one 

very  handsome  octavo  volume  of  925  pages,  with  170  engravings. 
Cloth,  $4.75 ;  leather,  $5.75. 

Complete,  concise,  fully  abreast  of  Practical,  systematic,  complete  and 

the  times  and  needed  by  all  students  well    balanced. — Chicago  Med.   Re- 

and  practitioners. —  Univ.  Med.  Mag.  corder. 

An  exceedingly  valuable  text-book. 

LYONS  (ROBERT  D.).  A  TREATISE  ON  FEVER.  In  one  octavo 
volume  of  362  pages.     Cloth,  $2.25. 

MACKENZIE  (JOHN  NOLAND).  ON  THE  NOSE  AND  THROAT. 
Handsome  octavo,  about  600  pages,  richly  illustrated.     Preparing. 

MAISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA 
MEDICA.  New  (7th)  edition,  thoroughly  revised  by  H.  C.  C.  Maisch, 
Ph.  G.,  Ph.  D.  In  one  very  handsome  12mo.  volume  of  512  pages,  with 
285  engravings.     Just  ready.     Cloth,  $2.50,  net. 

Used  as  text-book  in  every  college  I  in  America.  The  work  has  no  equal, 
of  pharmacy  in   the  United  States    — Dominion  Med.  Monthly. 
and  recommended   in   medical   col-        The    best  handbook    upon  phar- 
leges. — American  Therapist.  macognosy  of  any  published  in  this 

Noted  on  both  sides  of  the  Atlantic    country. — Boston  Med.  &  Sur.  Jonr. 
and  esteemed  as  much  in  Germany  as 


20     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


MALSBARY  (GEORGE  E.).  A  POCKET  TEXT-BOOK  OF 
THEORY  AND  PRACTICE  OF  MEDICINE.  In  one  handsome 
12mo.  volume  of  405  pages,  with  45  illustrations.  Just  ready..  Cloth, 
$1.75,  net;  flexible  red  leather,  $2.25,  net.  Lea's  Series  of  Pocket 
Text-books,  edited   by  Bern  B.  Gallatjdet,  M.  D.    See  page  18. 

MANUALS.  See  Student's  Quiz  Series,  page  27,  Student's  Series  of 
Manuals,  page  27,  and  Series  of  Clinical  Manuals,  page  25. 

MARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  In  one  12mo. 
volume  of  468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

MARTIN  (EDWARD).  A  MANUAL  OF  SURGICAL  DIAGNOSIS. 
In  one  12mo.  volume  of  about  400  pp.,  fully  illustrated.     Preparing. 

MARTIN  (TV ALTON)  AND  ROCKWELL,  (WM.  H.).  A  POCKET 
TEXT-BOOK  OF  CHEMISTRY  AND  PHYSICS.  In  one  hand- 
some 12mo.  volume  of  about  350  pages,  with  many  illustrations. 
Shortly.  Lea's  Series  of  Pocket  Text-books,  edited  by  Bern  B. 
Gallatjdet,  M.  D.    See  page  18. 

MAY  (C.  H.).  MANUAL  OF  THE  DISEASES  OF  WOMEN.  For 
the  use  of  Students  and  Practitioners.  Second  edition,  revised  by  L. 
S.  Ratt,  M.  D.  In  one  12mo.  volume  of  360  pages,  with  31  engrav- 
ings.   Cloth,  $1.75. 

3LEDICAL  NEWS  POCKET  FORMULARY,  see  page  32. 

MITCHELL  (S.  WEIR).  CLINICAL  LESSONS  ON  NERVOUS 
DISEASES.  In  one  12mo.  volume  of  299  pages,  with  19  engravings 
and  2  colored  plates.  Cloth,  $2.50.  Of  the  hundred  numbered  copies 
with  the  Author's  signed  title  page  a  few  remain ;  these  are  offered 
in  green  cloth,  gilt  top,  at  $3.50,  net. 


The  book  treats  of  hysteria,  recur- 
rent melancholia,  disorders  of  sleep, 
choreic  movements,  false  sensations 
of  cold,  ataxia,  hemiplegic  pain, 
treatment  of  sciatica,  erythromelal- 
gia,  reflex  ocularneurosis,  hysteric 

MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  IN- 
JURIES OF  NERVES  AND  THEIR  TREATMENT.  In  one 
handsome  12mo.  volume  of  239  pages,with  12  illustrations.  Cloth,  $1.75. 


contractions,  rotary  movements  in 
the  feeble  minded,  etc.  Few  can 
speak  with  more  authority  than  the 
author. —  The  Journal  of  the  Ameri- 
can Medical  Association. 


Injuries  of  the  nerves  are  of  fre- 
quent occurrence  in  private  practice, 
and  often  the  cause  of  intractable 
and  painful  conditions,  conse- 
quently this  volume  is  of  especial 
interest.     Doctor  Mitchell  has  had 


access  to  hospital  records  for  the  last 
thirty  years,  as  well  as  to  the 
government  documents,  and  has 
skilfully  utilized  his  opportunities. 
—  The  Med.  Age. 


MORRIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  New  (2d) 
edition.  In  one  12mo.  volume  of  <><H  pages,  with  10  chromo-litlm- 
graphic  plates  and  26    engravings.     Cloth,  $3.25,   net.    Just  ready. 

MTTLLER  (J.).  PRINCIPLES  OF  PHYSICS  AND  METEOROL- 
OGY.    In  one  large  8vo.  vol.  of  623  pages,  with  538  cuts.  Cloth,  $4.50. 


Lea  Bbothebs  &  Co.,  Philadelphia  and  New  York.     21 


MTJSSER  JOHN  H.).    A  PRACTICAL  TREATISE  ON  MEDICAL 

DIAGNOSIS,  for  Students  and  Physicians.     New  (3d)  edition,  thor- 
oughly revised.     In  one  octavo  volume  of  1082  pages,  with  2.53  en- 
gravings and  48  full-page  colored  plates.     Just  ready.     Cloth,  $6.00, 
net  •   leather,  $7.00,  net. 
Notices  of  previous  edition  are  appended. 

We  have  no  work  of  equal  value        It  so  thoroughly  meets  the  precise 


University    Medical 


demands  incident  to  modern  research 
that  it  has  been  adopted  as  a  leading 
text-book  by  the  medical  colleges 
of  this  country. — North  American 
Practitioner. 


iu    English. 
Magazine. 

His  descriptions  of  the  diagnostic 
manifestations  of  diseases  are  accu- 
rate. This  work  will  meet  all  the 
requirements  of  student  and  physi- 
cian . —  The  Med ica I  News. 

From  its  pages  may  be  made  the    thorough,  systematic  treatise, 
diagnosis    of   every  "  malady    that    Medical  Journal. 
afflicts  the  human    body,   including 
those  which   in   general    are  dealt 
with  only  by  the  specialist. — North- 
western Lancet. 


Occupies  the  foremost  place  as  a 
Ohio 


The  best  of  its  kind,  invaluable  to 
the  student,  general  practitioner  and 
teacher. — Montreal  Medical  Journal . 

NATIONAL  DISPENSATORY.  See  Stille,  Maisch  &  Caspari,  p.  27. 

NATIONAL  FORMULARY.  See  Stille,  Maisch  &  Caspari's  National 
Dispensatory,  page  27. 

NATIONAL  MEDICAL  DICTIONARY.     See  Billings,  page  4. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.    New  (5th)  American 
from  sixth  English  edition,  thoroughly  revised.     In  one  12mo.  volume 
of  521  pages,  with  161  engravings,  and  2  colored  plates,  test-types, 
formulae  and  color-blindness  test.     Cloth,  $2.25.     Just  ready. 
By  far  the  best  student's  text-book  English     language.  —  Journal      of 
on  the  subject  of  ophthalmology  and  Medicine  and  Science. 
is  conveniently  and    concisely    ar-       The  present  edition  is  the  result 
ranged. —  The  Clinical  Review.  of  revision  both   in     England  and 

It  has  been  conceded  by  ophthal-  America,  and  therefore  contains  the 
mologists  generally  that  this  work  latest  and  best  ophthalmological 
for  compactness,  practicality  and  ideas  of  both  continents. — The  Phy- 
clearness    has   no   superior     in    the   sician  and  Surgeon. 

NICHOLS  (JOHN  B.)  AND  YALE  (F.  P.).  A  POCKET  TEXT- 
BOOK OF  HISTOLOGY  AND  PATHOLOGY.  In  one  handsome 
12mo.  volume  of  452  pages,  with  213  illustrations.  Just  ready.  Cloth, 
$1.75,  net :  flexible  red  leather,  $2.25,  net. 

Lea's  Serin  of  Pocket  Text-books,  edited  by  Bern  B.  Gallaudet, 
M.  D.     See  page  18. 

NORRIS  (WM.  F.  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF 
OPHTHALMOLOGY.  In  one  octavo  volume  of  641  pages,  with  357 
engravings  and  5  colored  plates.     Cloth,  $5  ;  leather,  $6. 


A  safe  and  admirable  guide,  well 
qualified  to  furnish  a  working 
knowledge  of  ophthalmology.  — 
Johns  Hopkins  Hospital  Bulletin. 

It  is  practical  in  its  teachings. 
We  unreservedly  endorse  it  as  the 


best,  the  safest  and  the  most  compre- 
hensive volume  upon  the  subject  that 
has  ever  been  oftered  to  the  Amer- 
ican medical  public. — Annals  of 
Ophthalmology  and  Otology. 


22     Lea  Brothers  &wCo.,  Philadelphia  and  New  York. 


OWEN    (EDMUND).      SURGICAL    DISEASES    OF    CHILDREN. 

In  one  12mo.  volume  of  525  pages,  with  85  engravings  and  4  colored 
plates.     Cloth,  $2.     See  Series  of  Clinical  Manuals,  page  25. 

PARK  (ROSWELL).  A  TREATISE  ON  SURGERY  BY  AMERI- 
CAN AUTHORS.  New  and  condensed  edition.  Just  ready. 
In  one  royal  octavo  volume  of  1261  pages,  with  Gib  engravings 
and  37  full-page  plates.  Cloth,  $6.00,  net;  leather,  $7X)0,  net. 
^©"This  work  is  also  published  in  a  larger  edition,  comprising  two 
volumes.  Volume  I.,  General  Surgery,  799  pages,  with  356  engravings 
and  21  full-page  plates,  in  colors  and  monochrome.  Volume  II., 
Special  Surgery,  800  pages,  with  430  engravings  and  17  full-page 
plates,  in  colors  and  monochrome.  Per  volume,  cloth,  $4.50 ;  leather, 
$5.50,  net. 


The  work  is  fresh,  clear  and  practi- 
cal, covering  the  ground  thoroughly 
yet  briefly,  and  well  arranged  for 
rapid  reference,  so  that  it  will  be  of 
special  value  to  the  student  and  busy 
practitioner.  The  pathology  is 
broad,  clear  and  scientific,  while  the 
suggestions  upon  treatment  are 
clear-cut,  thoroughly  modern  and 
admirably  resourceful. — Johns  Hop- 
kins Hospital  Bulletin. 

The  latest  and  best  work  written 
upon  the  science  and  art  of  surgery. 
Columbus  Medical  Journal. 

The  illustrations  are  almost  en- 
tirely new  and  executed  in   such   a 


way  that  they  add  great  force  to  the 
text. —  The  Chicago  Medical  Re- 
corder. 

The  various  writers  have  em- 
bodied the  teachings  accepted  at 
the  present  hour. — The  North  Amer- 
ican Practitioner. 

Both  for  the  student  and  practi- 
tioner it  is  most  valuable.  It  is 
thoroughly  practical  and  yet  thor- 
oughly scientific. — Medical  News. 

A  truly  modern  surgery,  not  only 
in  pathology,  but  also  in  sound 
surgical  therapeutics.  —  New  Or- 
leans Med.  and  Surgical  Journal. 


PARK  (WILLIAM  H.).  BACTERIOLOGY  IN  MEDICINE  AND 
SURGERY.  12mo.,  688  pages,  with  87  illustrations  in  black  and 
colore,  and  2  plates.     Just  read;/.     Cloth,  $3.00  net. 

PARRY  (JOHN  S.).  EXTRA-UTERINE  PREGNANCY,  ITS 
CLINICAL  HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREAT- 
MENT.    In  one  octavo  volume  of  272  pages.    Cloth,  $2.50. 


PARVEN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OB- 
STETRICS. Third  edition.  In  one  handsome  octavo  volume  of 
677  pageB,  with  267  engravings  and  2  colored  plates.  Cloth,  $4.25 ; 
leather,  $5.25. 


In  the  foremost  rank  among  the 
most  practical  and  scientific  medical 
works  of  the  day. — Medical  News. 

The  book  is  complete  in  every  de- 
partment, and  contains  all  the  neces- 
sary detail  required  by  the   modern 


practising    obstetrician.  —  Interna- 
tional Medical  Magazine. 

Parv iii's  work  is  practical,  con- 
cise and  comprehensive.  We  com- 
mend it  as  first  of  its  class  in  the 
English  language. — Medical  Fort- 
nightly. 


Lea  Brothers  &  Co.,  Philadelphia  ani>  New  York.     23 


PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  3. 

PEPPER  (A.  J.).     FORENSIC  MEDICINE.    In  press.    See  Student's 
Series  of  Manuals,  page  27. 

SURGICAL  PATHOLOGY.     In  one  12mo.  volume  of  511  pages, 


with  81  engravings.   Cloth,  $2.   See  Student's  Series  of  Manuals,  p.  27. 

PICK  (T.  PICKERING  .  FRACTURES  AND  DISLOCATIONS. 
In  one  12mo.  volume  of  530  pages,  with  93  engravings.  Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  25. 

PliAYFAIR  (W.   S.).      A  TREATISE  ON    THE  SCIENCE   AND 
PRACTICE  OF  MIDWIFERY.     Seventh  American  from  the  ninth 
English  edition.     In   one  octavo   volume  of  700    pages,    with    207 
engravings  and  7  plates.     Cloth,  $3.75  net;  leather,  $4.75,  net.    Jtist 
ready. 
In  the  numerous  editions   which    obstetrician.    It  holds  a  place  among 
have  appeared  it  has  been  kept  con-    the  ablest  English-speaking  authori- 
stantly  in  the  foremost  rank.     It   is    ties  on  the   obstetric    art. — Buffalo 
a  work  which  can  be  conscientiously    Medical  and  Surgical  Journal. 
recommended   to   the    profession. —  t      An   epitome  of  the  science    and 
The  Albany  Medical  Annals.  [practice   of   midwifery,   which   em- 

This  work   must   occupy   a  fore-    bodies   all  recent  advances.  —  The 
most  place  in  obstetric  medicine  as    Medical  Fortnightly. 
a  safe  guide  to  both  student  and 

THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRA- 


TION   AND    HYSTERIA.      In   one  12mo.  volume    of   97    pages. 
Cloth,  $1. 

POCKET  FORMULARY,  see  page  32. 

POCKET  TEXT-BOOKS,  see  page  IS. 

POLITZER  ADA»L.  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE 
EAR  AND   ADJACENT   ORGANS.     Second   American   from  the 
third   German  edition.      Translated   by   Oscar   Dodd,   M.  D.,   and 
edited  by  Sir  William  Dalby,  F.  R.  C.  S.    In  one  octavo  volume  of 
748  pages,  with  330  original  engravings.     Cloth,  $5.50. 
The   anatomy  and    physiology  of  ment  are  clear  and   reliable.     We 
each    part   of  the  organ  of  hearing    can  confidently  recommend  it,  for  it 
are    carefully   considered,  and  then    contains  all  tl>at  is  known  upon  the 
follows  an  enumeration  of  the  dis-    subject. — London  Lancet. 
eases  to  which  that  special   part  of       A  safe  and   elaborate  guide  into 
the  auditory  apparatus  is  especially    every  part    of  otology. — American 
liable.     The   indications    for  treat-    Journal  of  the  Medical  Sciences. 

POTTS  (CHARLES  S.).  A  POCKET  TEXT-BOOK  OF  NERVOUS 
AND  MENTAL  DISEASES.  In  one  handsome  12mo.  volume  of 
about  450  pages.  Shortly.  Lra's  S>'ri>s  of  Pocket  Text-books,  edited  by 
Berx  B.  Gallavdet,  M.  D.     See  page  18. 

PROGRESSIVE  MEDICINE,  see  page  32. 

PURDY  (CHARLES  W.\  BRIGHT'S  DISEASE  AND  ALLIED 
AFFECTIONS  OF  THE  KIDNEY.  In  one  octavo  volume  of  28S 
pages,  with  18  engravings.     Cloth,  $2. 


24     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 

PYE-SMITH  (PHILIP  H.).  DISEASES  OF  THE  SKIN.  In  one 
12mo.  vol.  of  407  pp.,  with  28  illus.,  18  of  which  are  colored.  Cloth,  $2. 

QUIZ  SERIES.     See  Student's  Quiz  Series,  page  27. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one 
12mo.  volume  of  314  pages,  with  16  engravings.  Cloth,  $1.50.  See 
Student's  Series  of  Manuals,  page  27. 

RAMSBOTHAM  (FRANCIS  H.).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  OBSTETRIC  MEDICINE  AND  SURGERY.  In  one 
imperial  octavo  volume  of  640  pages,  with  64  plates  and  numerous 
engravings  in  the  text.     Strongly  bound  in  leather,  $7. 

REICHERT  (EDWARD  T.).  A  TEXT-BOOK  ON  PHYSIOLOGY. 
In  one  handsome  octavo  volume  of  about  800  pages,  richly  illustrated. 
Preparing. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEM- 
ISTRY. New  (5th)  edition,  thoroughly  revised.  In  one  12mo.  vol- 
ume of  326  pages.     Cloth,  $2. 

A   clear  and  concise  explanation  that  the  work  has  met  with  general 

of  a  difficult  subject.     We  cordially  favor.    This  is  further   established 

recommend  it. —  The  London  Lancet,  by  the  fact  that  it  has  been   trans- 

The  book  is  equally  adapted  to  the  lated  into  German  and  Italian.    The 

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tioner  who  desires  to  broaden   his  laboratory  student.    It  ranks  unusu- 

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— New  Orleans  Med.  and  Surg.  Jour,  class.  This  edition  has  been  brought 

The  appearance  of  a  fifth  edition  fully  up  to  the    times.— Amer lean 

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RICHARDSON  (BENJAMIN  WARD).  PREVENTIVE  MED1 
CINE.     In  one  octavo  volume  of  729  pages.     Cloth,  $4 ;  leather,  $5. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  New  (2d)  edition.  In  one  octavo  volume  of 
838  pages  with  473  engravings  and  8  plates.  Just  ready.  Oloth,  >4.l'~>. 
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ROBERTS  (SIR  WILLIAM).  A  PRACTICAL  TREATISE  ON 
URINARY  AND  RENAL  DISEASES,  INCLUDING  URINARY 
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one  very  handsome  8vo.  vol.  of  609  pp.,  with  81  illus.     Cloth,  $3.50. 

ROBERTSON  (J.  MCGREGOR).  PHYSIOLOGICAL  PHYSICS. 
In  one  12mo.  volume  of  537  pages,  with  219  engravings.  Cloth,  $2. 
See  Student's  Series  of  Manuals,  page  27. 

ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE 
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with  184  engravings.     Cloth,  $4.50 ;  leather,  $5.50. 

SAVAGE  (GEORGE  H.).  INSANITY  AND  ALLIED  NEUROSES, 
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with  18  typical  engravings.  Cloth,  $2.  See  Series  of  Clinical  Man- 
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SOHAFER  (EDWARD  A.).  THE  ESSENTIALS  OF  HISTOL- 
OGY, DESCRIPTIVE  AND  PRACTICAL.  For  the  use  of  Students. 
New  (5th)  edition.  In  one  handsome  octavo  volume  of  359  pages, 
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The  most  satisfactory  elementary 
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In  one  12mo.  volume  of  307  pages,  with  59  engravings.    Cloth,  $2.25. 

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SCHRELBER  (JOSEPH).  A  MANUAL  OF  TREATMENT  BY 
MASSAGE  AND  METHODICAL  MUSCLE  EXERCISE.  Octavo 
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SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edi- 
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For  separate  notices,  see  under  various  authors'  names. 

SERIES  OF  STUDENT'S  MANUALS.     See  page  27. 

SIMON    (CHARLES  E.).     CLINICAL    DIAGNOSIS,   BY  MICRO- 
SCOPICAL AND  CHEMICAL  METHODS.     New  (2d)  edition.    In 
one  very  handsome  octavo  volume  of  530  pages,  with  135  engravings 
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Journal. 


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SIMON  (TV.).  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures 
and  Laboratory  Work  for  Beginners  in  Chemistry.  A  Text-book 
specially  adapted  for  Students  of  Pharmacy  and  Medicine.  New  (6th) 
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who  devotes  himself  to  the  practice        Its  statements  are  all  clear  and  its 

of  medicine  need  know  more  about    teachings    are  practical. —  Virginia 

chemistry  than  is  contained  between    Jled.  Monthly. 

SLADE  (D.  D.).  DIPHTHERIA;  ITS  NATURE  AND  TREAT- 
MENT. Second  edition.  In  one  royal  12mo.  vol.,  158  pp.   Cloth,  $1.25. 

SMITH  (EDWARD).  CONSUMPTION;  ITS  EARLY  AND  REME- 
DIABLE STAGES.     In  one  8vo.  volume  of  253  pp.     Cloth,  $2.25. 

SMITH  (J.  LEWIS).  A  TREATISE  ON  THE  DISEASES  OF  IN- 
FANCY AND  CHILDHOOD.  Eighth  edition,  thoroughly  revised 
and  rewritten  and  much  enlarged.     In  one  large  8vo.  volume  of  983 

{(ages,   with   273   engravings  and   4  full-page  plates.     Cloth,  $4.50; 
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Chicago  Medical  Recorder. 

SMITH  (STEPHEN).     OPERATIVE  SURGERY.    Second  and  thor- 
oughly revised  edition.      In  one  octavo  volume  of  892  pages,  with 
1005  engravings.     Cloth,  $4  ;  leather,  $5. 
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published.    The  book  is  a  compen-  | 

SOLLY  (S.  EDWIN).      A  HANDBOOK   OF  MEDICAL  CLIMA- 
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Just  ready. 
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to  its  influence  upon  human  beings.        Every    practitioner    of    medicine 
—  The  Therapeutic  Gazette.  should  possess  himself  of  a  copy  and 

The  book  is  admirably  planned,  study  it,  and  we  are  sure  he  will 
clearly  written,and  the  author  speaks  never  regret  it. — St.  Louis  Medical 
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8TILLE  ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUS- 
ATION, SYMPTOMS,  LESIONS,  PREVENTION  AND  TREAT- 
MENT. In  one  12mo.  volume  of  163  pages,  with  a  chart  showing 
routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS   AND    MATERIA    MEDICA.      Fourth    and 

revised   edition.      In   two   octavo   volumes,  containing    1936    pages. 
Cloth,  $10;  leather,  $12. 


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STILiLJE   (ALFRED),   MAISCH    (JOHN  M.)   AND    CASPAR! 

(CHAS.  JR.).  THE  NATIONAL  DISPENSATORY:  Containing 
the  Natural  History,  Chemistry,  Pharmacy,  Actions  and  Uses  of 
Medicines,  including  those  recognized  in  the  latest  Pharmacopoeias  of 
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Thumb-letter  Index.     Cloth,  $7.75  ;  leather,  $8.50. 

STIMSON  (LEWIS  A.).    A  MANUAL  OF  OPERATIVE  SURGERY. 

New  (3d)  edition.  In  one  royal  12mo.  volume  of  614  pages,  with  306 
engravings.     Cloth,  $3.75. 

A  useful  and  practical  guide  for 


all  students  and  practitioners. — Am. 
Journal  of  the  3Iedical  Sciences. 


The  book  is  worth  the  price  for  the 
illustrations  alone. —  Ohio  31edical 
Journal. 


STIMSON  (LEWIS  A.).     A  TREATISE  ON   FRACTURES    AND 

DISLOCATIONS.  In  one  handsome  octavo  volume  of  831  pages, 
with  326  engravings  and  20  plates.  Cloth,  $5.00,  net;  leather, 
$6.00,  net. 

Preeminently  the  authoritative  I  Taken  as  a  whole,  the  work  is  the 
text-book  upon  the  subject.  The  \  best  one  in  English  to-day. — St. 
vast  experience  of  the  author  gives  :  Louis  Medical  and  Surgical  Journal. 
to  his  conclusions  an  unimpeachable  |  Pointed,  practical,  comprehensive, 
value.  The  work  is  profusely  il-  exhaustive,  authoritative,  well  writ- 
lustrated.  It  will  be  found  indis-  j  ten  and  well  arranged. — Denver 
pensable  to  the  student  and  the  prac-  Medical  Times. 
titioner  alike. — The  Medical  Age. 

STUDENT'S  QUIZ  SERD3S.  Thirteen  volumes,  convenient,  author- 
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urinary and  Venereal  Diseases;  9.  Diseases  of  the  Skin;  10.  Diseases 
of  the  Eye,  Ear,  Throat  and  Nose;  11.  Obstetrics;  12.  Gynecology; 
13.  Diseases  of  Children.  Price,  $1  each,  except  Nos.  1  and  7, 
Anatomy  and  Surgery,  which  being  double  numbers  are  priced  at 
$1.75  each.     Full  specimen  circular  on  application  to  publishers. 

STUDENT'S  SERIES  OF  MANUALS.  12mos.  of  from  300-540 
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Bell's  Comparative  Anatomy  and  Physiology,  $2 ;  Robert- 
son's Physiological  Physics,  $2;  Gould's  Surgical  Diagnosis,  $2; 
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Surgical  Pathology,  $2 ;  Treves'  Surgical  Applied  Anatomy,  $2 ; 
Ralfe's  Clinical  Chemistry,  $1.50;  and  Clarke  and  Lockwood's 
Dissector's  Manual,  $1.50.  The  following  is  in  press :  Pepper's 
Forensic  Medicine. 
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28     Lea  Brothers  A  Co.,  Philadelphia  and  New  York. 


STURGES  (OCTAVITJS).  AN  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE 
OVARIES  AND  FALLOPIAN  TUBES.  Including  Abdominal 
Pregnancy.  In  one  12mo.  volume  of  513  pages,  with  119  engravings 
and  5  colored  plates.     Cloth,  $3. 

TAIT  (LAWSON).     DISEASES   OF  WOMEN  AND  ABDOMINAL 

SURGERY.     Vol.  I.  contains  546  pages  and  3  plates.    Cloth,  $3. 


TANNER  (THOMAS  HAWKES)  ON  THE  SIGNS  AND  DIS- 
EASES OF  PREGNANCY.  From  the  second  English  edition.  In 
one  octavo  volume  of  490  pages,  with  4  colored  plates  and  16  engrav- 
ings.    Cloth,  $4.25 

TAYLOR  (ALFRED  S.).  MEDICAL  JURISPRUDENCE.  New 
American  from  the  twelfth  English  edition,  specially  revised  by  Clark 
Bell,  Esq.,  of  the  N.  Y.  Bar.  In  one  8vo.  vol.  of  831  pages,  with  54 
engrs.  and  8  full-page  plates.  Cloth,  $4.50;  leather,  $5.50  Just  ready. 
To  the  student,  as  to  the  physician,  I  nesses,  it  strongly  behooves  them  to 


we  would  say,  get  Taylor  first,  and 
then  add  as  means  and  inclination 
enable  you. — American  Practitioner 
and  News. 

It  is  the  authority  accepted  as 
final  by  the  courts  of  all  English- 
speaking  countries.  This  is  the  im- 
portant consideration  for  medical 
men,  since  in  the  event  of  their 
being  summoned  as  experts  or  wit- 


be  prepared  according  to  the  princi- 
ples and  practice  everywhere  ac- 
cepted. The  work  will  be  found  to 
be  thorough,  authoritative  and 
modern. — Albany  Law  Journal. 

Probably  the  best  work  on  the 
subject  written  in  the  English  lan- 
guage. The  work  has  been  thor- 
oughly revised  and  is  up  to  date. — 
Pacific  Medical  Journal. 


ON  POISONS  IN  RELATION  TO  MEDICINE  AND  MEDI- 
CAL JURISPRUDENCE.  Third  American  from  the  third  London 
edition.  In  one  octavo  volume  of  788  pages,  with  104  illustrations. 
Cloth,  $5.50 ;  leather,  $6.50. 

TAYLOR  (ROBERT  W.).  THE  PATHOLOGY  AND  TREAT- 
MENT OF  VENEREAL  DISEASES.  In  one  very  handsome  octavo 
volume  of  1002  pages,  with  230  engravings  and  8  colored  plates. 
<  loth,  $6.00,  net;  leather,  $6.00,  net. 


By  Lone  odds  the  best  work  on 
venereal  diseases. — Louisville  Medi- 
I'd  \fonthly. 

In  the  observation  and  treatment 
of  venereal  diseases  his  experience 
has  been  greater  probably  than  that 
of  any  Other  practitioner  of  this  con- 
tin  >•  1 1 1, .  - Ne w  Yo rk  Medicu I  Journal. 

The  clearest,  most  unbiased  and 
ably  presentee!  in-atise  as  yet  pub- 
lished on  this  vast  subject. — The 
\fecttcal  News. 

D<cidedly  the  most  important  and 
authoritative  treatise    on    venereal 


diseases  that  has  in  recent  years  ap- 
peared in  English. — American  .loin- 
iml  of  the  Medical  Sciences. 

It  is  a  veritable  storehouse  of  our 
knowledge  of  the  venereal  diseases. 
It  is  commended  as  a  conservative, 
practical,  full  exposition  of  the 
greatest  value. — Chicago  Clinical 
Review. 

The  best  work  on  venereal  dis- 
eases in  the  English  language.  It 
is  certainly  above  everything  of  the 
kind. —  The  St.  Louis  Medical  and 
Surgical  Journal. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.     29 

TAYIiOR  (ROBERT  W.).  A  PRACTICAL  TREATISE  ON  SEX- 
UAL DISORDERS  IN  THE  MALE  AND  FEMALE.  In  one 
8vo.  vol.  of  448  pp.,  with  73  engravings  and  8  colored  plates. 

The  author  has  presented  to  the  [  followed,  will  be  of  unlimited  value 
profession  the  ablest  and  most  scien-  j  to    both    physician    and    patient. — 
tific  work  as  yet  published  on  sexual    Medical  News. 
disorders,  and  one  which,  if  carefully  1 

-A  CLINICAL  ATLAS  OF  VENEREAL  AND  SKIN  DISEASES. 


Including  Diagnosis,  Prognosis  and  Treatment.  In  eight  large  folio 
parts,  measuring  14  x  18  inches,  and  comprising  213  beautiful  figures 
on  58  full-page  chromo-lithographic  plates,  85  fine  engravings  and  425 
pages  of  text.  Complete  work  now  ready.  Price  per  part,  sewed  in 
heavy  embossed  paper,  $2.50.  Bound  in  one  volume,  half  Russia, 
$27  ;  half  Turkey  Morocco,  $28.  For  sale  by  subscription  only.  Address 
the  publishers.     Specimen  plates  by  mail  on  receipt  often  rents. 

TAYLOR  (SEYMOUR).  INDEX  OF  MEDICINE.  A  Manual  for 
the  use  of  Senior  Students  and  others.  In  one  large  12mo.  volume  of 
802  pages.     Cloth,  $3.75. 

THOMAS  (T.  GAIL.LARD)  AND  MUNDE(PAUL  P.).  A  PRAC- 
TICAL TREATISE  ON  THE  DISEASES  OF  WOMEN.  Sixth 
edition,  thoroughly  revised  by  Paul  F.  MUNDfi,  M.  D.  In  one 
large  and  handsome  octavo  volume  of  824  pages,  with  347  engravings. 
Cloth,  $5 ;  leather,  $6. 

This  work,  which  has  already  gone 
through  five  large  editions,  and  has 
been  translated  into  French,  Ger- 
man, Spanish  and  Italian,  is  the 
most  practical  and  at  the  same  time 
the  most  complete  treatise  upon  the 
subject. —  The  Archives  of  Gynecol- 
tive. — Boston  Med.  and  Sur.  Jonr.     '■  ogy,  Obstetrics  and  Pediatrics. 


The  best  practical  treatise  on  the 
subject  in  the  English  language. 
It  will  be  of  especial  value  to  the 
general  practitioner  as  well  as  to  the 
specialist.  The  illustrations  are  very 
satisfactory.  Many  of  them  are  new 
and  are  particularly  clear  and  attrac- 


THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DIS- 
EASES OF  THE  URINARY  ORGANS.  Second  and  revised  edi- 
tion.   In  one  octavo  vol.  of  203  pp.,  with  25  engravings.    Cloth,  $2.25- 

THE    PATHOLOGY   AND   TREATMENT   OF   STRICTURE 


OF  THE  URETHRA  AND  URINARY  FISTULA.  From  the 
third  English  edition.  In  one  octavo  volume  of  359  pages,  with  47 
engravings  and  3  lithographic  plates.     Cloth,  $3.50. 

THOMSON  (JOHN).     DISEASES  OF   CHILDREN.     In  one  crown 
octavo  volume  of  350  pages,  with  52  illus.  Cloth,  $1.75,  net.  Just  ready. 

TODD  (ROBERT  BENTLEY).     CLINICAL  LECTURES  ON  CER- 
TAIN ACUTE  DISEASES.    In  one  8vo.  vol.  of  320  pp.,  cloth,  $2.50. 

TREVES    (FREDERICK).      OPERATIVE    SURGERY.      In    two 
8vo.  vols,  containing  1550  pp.,  with  422  illus.     Cloth,  $9  ;  leath.,  $11. 

A  SYSTEM  OF  SURGERY.     In   Contributions  by  Twenty-five 

English  Surgeons.  In  two  large  octavo  volumes.  Vol.  I.,  1178  pages, 
with  463  engravings  and  2  colored  plates.  Vol.  II.,  1120  pages,  with 
487  engravings  and  2  colored  plates.     Complete  work,  cloth,  $16.00. 


30     Lea  Brothers  &  Co.,  Philadelphia  and  New  York. 


TREVES  (FREDERICK).    SURGICAL  APPLIED  ANATOMY.  In 

one  12mo.  volume  of  540  pages,  with  61  engravings.  Cloth,  $2.  See 
Student's  Series  of  Manuals,  page  27. 

TUTTL.E  (GEORGE  M.).  A  POCKET  TEXT-BOOK  OF  DISEASES 
OF  CHILDREN.  In  one  handsome  12mo.  volume  of  374  pages, 
with  5  plates.  Just  ready.  Cloth,  $1.50,  net;  flexible  red  leather, 
$2.00,  net.  Lea's  Series  'of  Purk,  i  Text-books,  edited  by  Bern  B. 
GALLATOET,  M.  D.    See  p.  18. 

VAUGHAN    (VICTOR    C.)    AND    NOW    (FREDERICK    G.). 

PTOMAINS,  LEUCOMAINS,  TOXINS  AND  ANTITOXINS, 
or  the  Chemical  Factors  in  the  Causation  of  Disease.  New  (3d)  edition. 
In  one  12mo.  volume  of  603  pages.     Cloth,  $3. 


The  present  edition  has  been  not 
only  thoroughly  revised  throughout 
but  also  greatly  enlarged,  ample 
consideration  being  given  to  the  new 
subjects  of  toxins  and  antitoxins. — 
TH- State  Medical  Journal. 


The  work  has  been  brought  down 
to  date,  and  will  be  found  entirely 
satisfactory. — Journal  of  the  Ameri- 
can Medical  Association. 

The  most  exhaustive  and  most  re- 
cent presentation  of  the  subject. — 
American  Jour,  of  the  Med.  Sciences.  ' 

VISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1900. 
Four  styles:  Weekly  (dated  for  30  patients);  Monthly  (undated  for 
120  patients  per  month) ;  Perpetual  (undated  for  30  patients  each 
week);  and  Perpetual  (undated  for  60  patients  each  week).  The  60- 
patient  book  consists  of  256  pages  of  assorted  blanks.  The  first  three 
styles  contain  32  pages  of  important  data,  thoroughly  revised,  and 
160  pages  of  assorted  blanks.  Each  in  one  volume,  price,  $1.25. 
With  thumb-letter  index  for  quick  use,  25  cents  extra.  Special  rates 
to  advance-paying  subscribers  to  The  Medical  News  or  The 
American  Journal  of  the  Medical  Sciences,  or  both.  See  p.  32. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  PHYSIC.  A  new  American  from  the  fifth  and 
enlarged  English  edition,  with  additions  by  H.  Hartshorns,  M.  D. 
In  two  large  8vo.  vols,  of  1840  pp.,  with  190  cuts.  Cloth,  $9 ;  leather,  $11. 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR 
TO  WOMEN.  Third  American  from  the  third  English  edition.  In 
one  octavo  volume  of  543  pages.     Cloth,  $3.75 ;  leather,  $4.75. 

ON   SOME  DISORDERS  OF  THE   NERVOUS  SYSTEM   IN 

CHILDHOOD.     In  one  small  12mo.  volume  of  127  pages.     Cloth,  $1. 

WHARTON  (HENRY  R.).  MINOR  SURGERY  AND  BANDAG- 
ING. New  (4th)  edition.  In  one  12mo.  volutin-  of  694  pages,  with 
602  engravings,  manv  of  which  are  photographic.  Just  ready.  $3.00, 
net. 

We  know  of  no  book  which  more 
thoroughly  or  more  satisfactorily 
ooren  'In-  .'round  of  Minor  Surgery 
and  Bandaging. — Brooklyn  Medical 

.Inn  null '. 

Well  written,  conveniently  ar- 
ranged and  amply  illustrated.  It 
covern  the  field  so  fully  as  to  render 
it  a  valuable  text-book,  aa  well  as  a 


work  of  ready  reference  for  sur- 
geons.— North  Amer.  Practitioner. 
The  part  devoted  to  bandaging  is 
perhaps  the  best  exposition  of  the 
subject  in  the  English  language.  It 
can  be  highly  commended  to  the 
student,  the  practitioner  and  the 
specialist. — The  Chicago  Medical 
Recorder. 


Lea  Brothers  &  Co.,  Philadelphia  and  New  York.      31 
WHITLA  (WHjLIAM).     dictionary  of  treatment,  or 

THERAPEUTIC  INDEX.     Including  Medical  and  Surgical  Thera- 
peutics.    In  one  square  octavo  volume  of  917  pages.     Cloth,  $4. 

WELLIAMS  (DAWSON).  THE  MEDICAL  DISEASES  OF  CHIL- 
DREN. In  one  12ino.  volume  of  629  pages,  with  18  illustrations. 
Just  ready.     Cloth,  $2.50,  net. 

The  descriptions  of  symptoms  are  diagnoses,  prognosis,  complications, 

full,  and  the  treatment  recommended  and  treatment.     The  work  is  up  to 

will  meet  general  approval.    Under  date  in  every  sense. —  The  Charlotte 

each  disease  are  given  the  symptoms,  Medic&l  Journal. 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY. 
A  new  and  revised  American  from  the  last  English  edition.  Illustrated 
with  397  engravings.  In  one  octavo  volume  of  616  pages.  Cloth,  $4 ; 
leather,  $5. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.    In 


one  12mo.  volume.     Cloth,  $3.50. 

WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
Translated  by  James  R.  Chadwick,  A.M.,  M.D.  With  additions 
by  the  Author.    In  one  octavo  volume  of  484  pages.     Cloth,  $4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
from  the  eighth  German  edition,  by  Ira  Remsen,  M.  D.  In  one 
12mo.  volume  of  550  pages.     Cloth,  $3. 

YEAR-BOOK  OF  TREATMENT  FOR  1892,  1893,  1896,1897  and  189S. 
Critical  Reviews  for  Practitioners  of  Medicine  and  Surgery.  In  con- 
tributions by  25  well-known  medical  writers.  12mos.,  about  500  pages 
each.  Cloth,  $1.50.  In  combination  with  The  Medical  News  and 
The  American  Journal  of  the  Medical  Sciences,  75  cents. 

YEO  (I.  BURNEY).  FOOD  IN  HEALTH  AND  DISEASE.  New 
(2d)  edition.  In  one  12mo.  volume  of  592  pages,  with  4  engravings. 
Cloth,  $2.50.     See  Series  of  Clinical  Manuals,  page  26. 

We  doubt  whether  any  book  on  I  work   of  Dr.   Yeo's.     The  value  of 
dietetics  has  been  of  greater  or  more    the  work  is  not  to  be  overestimated, 
widespread  usefulness  than  has  this    — New  York  Medical  Journal. 
much-quoted     and    much-consulted ' 

A  MANUAL   OF   MEDICAL   TREATMENT,  OR  CLINICAL 


THERAPEUTICS.  Two  volumes  containing  1275  pages.  Cloth,  $5.50. 

YOUNG  (JAMES  K.).    ORTHOPEDIC  SURGERY.     In    one    8vo. 
volume  of  475  pages,  with  286  illustrations.     Cloth,  $4;  leather,  $5. 

In  studying  the  different  chapters,  surgical  specialty   and   every  page 

one  is  impressed  with  the  thorough-  abounds    with    evidences    of  prac- 

ness  of  the  work.     The  illustrations  ticality.     It  is  the  clearest  and  most 

are  numerous — the  book  thoroughly  modern  work  upon  this  growing  de- 

practical — Medical  Hews.  partment  of  surgery. —  The  Chicago- 

It  is  a   thorough,  a  very  compre-  Clinical  Review. 
hensive  work  upon   this  legitimate 


PERIODICALS. 


PROGRESSIVE  MEDICINE. 

A  Quarterly  Digest  of  New  Methods,  Discoveries,  and  Improvements 
in  the  Medical  and  Surgical  Sciences  by  Eminent  Authorities.  Edited  by 
Dr.  Hobart  Amory  Hare.  In  four  abundantly  illustrated,  cloth  bound, 
octavo  volumes,  of  400-500  pages  each,  issued  quarterly,  commencing 
March  1st,  1899.     Per  annum  (4  volumes),  $10.00  delivered. 

THE  MEDICAL  NEWS. 

Weekly,  $4.00  per  Annum. 

Each  number  contains  32  quarto  pages,  abundantly  illustrated.  A 
crisp,  fresh  weekly  professional  newspaper. 


THE  AMERICAN  JOURNAL  OP  THE  MEDICAL  SCIENCES. 

Monthly,  $4.00  Per  Annum. 

Each  issue  contains  128  octavo  pages,  fully  illustrated.  The  most 
advanced  and  enterprising  American  exponent  of  scientific  medicine. 

THE   MEDICAL  NEWS  VISITING  LIST. 

Four  styles,  Weekly  (dated  for  30  patients) ;  Monthly  (undated,  for 
120  patients  per  month) ;  Perpetual  (undated,  for  30  patients  weekly  per 
year);  and  Perpetual  (undated,  for  60  patients  per  year).  Each  style  in 
one  wallet-shaped  book,  leather  bound,  with  pocket,  pencil  and  rubber. 
Price,  each,  $1.25.     Thumb-letter  index,  25  cents  extra. 


THE  MEDICAL  NEWS   POCKET  FORMULARY. 

Containing  1600  prescriptions  representing  the  latest  and  most  ap- 

[>roved   methods  of  adminktering  remedial   agents.     Strongly   bound  in 
lather  ;  with  pocket  and  pencil.     Price,  $1.50,  net. 


COMBINATION     RATES: 


}  $7-50l  $15.00 


American  Journal  of  the  Alone.  In  Combination. 

Medical  Sciences,      ....  $   4.00 

Medical  News 4.00 

Progressive  Medicine  ....      10.00 

Medical  News  Visiting  List         .        .         .         1.25 
Medical  News  Formulary  .        .         .         1.50  net, 

In  all  #20.75  for  $16.00 

First  four  above  publications  in  combination        .        .         $15.75 

All  above  publications  in  combination    ....  16. OO 

Other  Combinations  will    be  quoted  on  request. 

Full  Circulars  and  Specimens  free. 


LEA  BROTHERS  &  CO.,  Publishers, 

706,  708  &  710  Sansom   St.,  Philadelphia. 
Ill    Fifth  Avenue,  New  York. 


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